The Constitution of the World Health Organization specifies that the organization’s purpose is to “act as the direction and co-ordinating authority on international health work.” In the West African Ebola outbreak, though, WHO failed as a director and coordinator. Director-General Margaret Chan has said that WHO must change before the next global pandemic. Chatham House, the Royal Institute of International Affairs in London, has called WHO “overly-politicized,” “too bureaucratic,” and “timid.” An interim assessment report of WHO’s Ebola response recognized the complexity of the outbreak, but lambasted the organization for its “serious gaps” in responding.
In response to these flaws, Chan announced a series of reforms to WHO at the opening of the Assembly. These reforms will:
- Establish a $100 million emergency reserve fund that can finance field operations for up to three months in response to an infectious disease outbreak;
- Create a rapid response team that can be deployed quickly to provide services on the ground;
- Set up a review committee to consider improvements to the International Health Regulations and their requirements that states set up robust disease surveillance systems; and
- Develop a semi-autonomous committee within WHO, insulated from political pressures, that will have responsibility for declaring global health emergencies.
These reforms may change how WHO operates, but they are not the sorts of reforms that will fundamentally alter its operations or address its most striking shortcomings: WHO’s relationship with regional health organizations, and the size and flexibility of its budget. I highlighted these issues in an article I wrote in PS: Political Science and Politics earlier this year as part of a special symposium on the politics and policy of Ebola, and they will continue to impede WHO’s ability to lead effective international responses to disease outbreaks.
What about structural reforms?
WHO has an unwieldy structure, with the Geneva-based headquarters sharing power and authority with six regional organizations. Each regional organization has its own budget and sets its own priorities, which may or may not align with WHO’s larger priorities. This high degree of autonomy for the regional organizations can make coordination on global health priorities difficult. Indeed, one of the factors cited by commentators for WHO’s delayed response to Ebola was the strained relationship between Geneva and the Regional Office for Africa (AFRO). Reports suggested that representatives from AFRO were not included in early coordination efforts, and the country office in Guinea reportedly refused to help procure visas for WHO officials and blocked initial aid disbursements.
Despite the inefficiencies of this system, there has been no serious discussion about addressing these structural obstacles. The current arrangement arose for historical and political reasons that may have made sense in the 1940s, but they limit WHO’s operations today. The current system depends far too heavily on personal relationships and turf battles, which gets in the way of addressing global health concerns.
Where is the money?
The creation of a $100 million reserve fund will give WHO some degree of flexibility to implement immediate responses to outbreaks, but it masks the larger problems that gave rise to the need for the reserve fund in the first place. Simply put, WHO is under-resourced and has far too little control over its budget.
While the demands placed on WHO have grown in recent years, its budget has shrunk and is incommensurate with its responsibilities. In 2011, WHO had to cut its proposed budget by more than $1 billion due to a downturn in contributions. This forced WHO to cut more than 300 jobs and significantly reduce its funding for emergency response operations. Its 2014-2015 budget of $3.98 billion was far less than the Centers for Disease Control and Prevention’s $6 billion budget for a single year. The proposed 2016-2017 budget of $4.38 billion is an increase of more than 10 percent and will require a mix of assessed and voluntary contributions to realize.
WHO’s funding comes from two sources: regular budgetary funds (RBFs), which are the membership dues assessed to each state, and extrabudgetary funds (EBFs), which states and other organizations voluntarily give to WHO for specific projects. WHO has complete control over how it allocates its RBFs, but donors have control over the allocation of EBFs. Over time, EBFs have become a larger portion of WHO’s overall budget. In 1970, EBFs made up about 20 percent of the budget. For the 2014-2015 biennium, EBFs made up 78 percent of the budget. As the EBF portion of the budget increases, WHO’s control over its budget decreases.
Furthermore, WHO lacks the flexibility to shift funds around in an emergency like the Ebola outbreak. Instead of reallocating existing funds, WHO had to ask the international community to provide additional voluntary contributions and then wait for those funds, which further delayed its response. The reserve fund may allow WHO to respond more quickly in the future, but the need to create it shows the problems in WHO’s lack of budgetary flexibility.
In theory, WHO member-states could change their assessed dues to give the organization greater budgetary discretion, but they are unwilling to do so. The increases in the 2016-2017 budget will have to be financed entirely by increased voluntary contributions. The $100 million reserve fund will also rely entirely on voluntary funding for its creation and replenishment. While member-states have said that WHO must be better prepared to address the next disease outbreak, they have not committed to providing the finances necessary to ensure that can happen.
The World Health Organization finds itself at a crossroads. It failed in its biggest test of marshaling an international response to an infectious disease outbreak, and it acknowledges the need to change. The international community also recognizes the need for WHO to exist and its unique role. To make sure that WHO is ready and able to address future challenges, this year’s World Health Assembly must begin a much more far-reaching process of reform.
Jeremy Youde is an associate professor of political science and department head at the University of Minnesota Duluth. His most recent books are “The Politics of Surveillance and Response to Disease Outbreaks” (co-edited with Sara E. Davies) and “The Routledge Handbook of Global Health Security” (co-edited with Simon Rushton). Follow him on Twitter @jeremyyoude.