As the nations of the world attend the World Health Assembly in Geneva this week, the World Health Organization is in a budget crisis and continuing to struggle for relevancy among better-funded, more agile philanthropic foundations and disease-specific initiatives. Without a commitment to bold reform and greater efficiency, the future looks bleak for the world’s go-to international agency on public health.
Financial reform is on this week’s agenda, but it seems unlikely to attract donor and WHO member country support amid the global economic downturn. The capable Margaret Chan leads WHO and accepted her second five-year term as director-general this week, but there is a limit to what she can accomplish without resources. Survival for the institution is possible, but only if WHO reinvents itself as a twenty-first century international institution that can adapt to changing global health needs and thrive in austere times.
Until the 1990s, WHO was the most successful of the United Nations’ agencies. Launched in 1948, the organization served as a technical consultancy to national health ministers and international agencies, promoting the best practices to combat the worst diseases. Its accomplishments included overseeing the eradication of smallpox and pioneering the programs that now immunize most of world’s newborns against measles, polio, and yellow fever.
But WHO is also a political institution that represents the diverse health policy interests of its 194 member states. As its programs have expanded beyond infectious disease control to exploring the link between poverty and disease, the role of patent rights in medical innovation, health worker migration, and other disparate issues, donors began to question the agency’s performance and priorities. WHO member country fees have flatlined since the 1990s.
WHO became largely a bystander as interest in global health surged over the last two decades with the advent of the Bill and Melinda Gates Foundation and the extension of lifesaving treatment to millions through the U.S. President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Since 1990, global health aid has quadrupled to $22 billion annually, but WHO’s core budget remains the same, roughly $1 billion annually, and has declined in real terms.
In order to pay staff and maintain an extensive network of country and regional offices, WHO pursued voluntary contributions from public and private funders, which now comprise 80 percent of its operating budget. The grants are earmarked to diverse donor priorities and further diminish the coherence of WHO programs. The amounts are also insufficient to meet WHO’s current institutional needs. Last year, a $300 million budget shortfall forced WHO to lay off a quarter of its employees.
Yet global health needs are changing in ways that demand a strong and effective WHO. The world is more vulnerable than ever to the emerging microbial threats, such as pandemic flu, that cross borders with the exponential growth in trade and travel. Non-communicable diseases (NCDs) such as cancer, diabetes, respiratory and cardiovascular diseases are now the leading causes of death and disability in nearly every region of the world, and, according to the World Economic Forum (PDF), pose a greater threat to global economic development than fiscal crises, natural disasters, transnational crime and corruption, or infectious disease.
The most effective measures against these challenges are not, for the most part, the money or new medicines that philanthropic donors and bilateral initiatives can offer. The best tools against emerging microbial threats and NCDs are prevention and control, which require evidence-based ideas and the global surveillance, technical assistance, and international coordination that can support their effective and sustained implementation.
WHO has long specialized in these functions and would be well-placed to do so again, but it must first recalibrate its resources to reflect changed global circumstances. When communication and transportation between continents were slow, WHO may have needed country representatives to sit together in Geneva and to invest the brick, mortar, and hardship pay to staff 6 regional and 147 country offices, but this is no longer the case.
Developing country officials that were once reliant on WHO for supplying advice and expertise on basic health programs now have other needs. Most low- and middle-income countries have trained staff to manage their own health services, but require technical support and data on the best global practices to do so more effectively. In opening this week’s assembly, Director-General Chan observed that many of the greatest successes of global health are occurring at the country level and with the leadership of local government officials. These officials should be partners, not merely patrons, in WHO’s efforts against global disease.
WHO must reinvent itself as a twenty-first century international institution in which its central functions in Geneva are streamlined and tightly prioritized to the cross-border health challenges that countries and donors cannot themselves address. The real work of the organization should be performed not by WHO employees in regional and country offices, but by technical professionals resident in the public health authorities within member states. WHO resources should not longer go primarily to its own staff and the maintenance of regional and country offices, but to those public health authorities that develop the capacity to engage in global networks to address emerging microbial threats, NCDs, and other cross-border health threats.
This proposal is ambitious, but hardly unprecedented. The U.S. Centers for Disease Control and Prevention have long relied on programs such as the Epidemic Intelligence Service, in which a core of technical experts based in its Atlanta headquarters draws on the expertise available in the field to monitor and control disease. The Pan American Health Organization (PAHO), a WHO regional office, has recently taken steps in this direction with its launch of a network that will engage capable national regulatory authorities to provide the technical support that peer-country regulators need and now PAHO itself need no longer supply.
As member states gather at the World Health Assembly and debate financing reforms to recapitalize the WHO, they should first articulate an institutional vision that can attract donor and member country support and revitalize the institution as the world’s defender against the 21st century challenges of global disease.