[Ip-health] Devi Sridhar, Lawrence O. Gostin in JAMA: Reforming the World Health Organization

Thiru Balasubramaniam thiru at keionline.org
Wed Mar 30 02:32:04 PDT 2011



JAMA. Published online March 29, 2011. doi: 10.1001/jama.2011.418
Reforming the World Health Organization
	• Devi Sridhar, DPhil;
	• Lawrence O. Gostin, JD
Author Affiliations

Author Affiliations: Department of Politics and International  
Relations, University of Oxford, Oxford, England (Dr Sridhar); and  
O’Neill Institute for National and Global Health Law, Georgetown  
University Law Center, Washington, DC (Mr Gostin).

Corresponding Author: Lawrence O. Gostin, JD, Georgetown University  
Law Center, 600 New Jersey Ave NW, Washington, DC 20001 (gostin at law.georgetown.edu 

In December 2010, Jack Chow,1 the former World Health Organization  
(WHO) assistant director-general, asked, “Is the WHO becoming  
irrelevant?” A month later, the WHO's executive board considered the  
agency's future within global health governance. After a year-long  
consultation with member states on its financing, Director-General  
Margaret Chan called the WHO overextended and unable to respond with  
speed and agility to today's global health challenges.2

The crisis in leadership is not surprising to those familiar with the  
WHO. As its first specialized agency, the United Nations (UN) endowed  
the WHO with extensive normative powers to act as the directing and  
coordinating authority on international health. Yet modern global  
health initiatives (eg, the Global Fund to Fight AIDS, Tuberculosis  
and Malaria and the GAVI Alliance [formerly the Global Alliance for  
Vaccines and Immunisation]), bilateral programs (eg, US President's  
Emergency Plan for AIDS Relief [PEPFAR]), and well-funded  
philanthropies (eg, the  Bill & Melinda Gates Foundation) often  
overshadow the agency. The WHO can be subject to political pressure,  
and its relationship with industry and civil society is uncertain.3

Given the importance of global health cooperation, few would dispute  
that a stronger, more effective WHO would benefit all. The WHO's  
internal reform agenda must be bold to ensure its future. In this  
Commentary, we offer 5 proposals for reestablishing the agency's  

Give Real Voice to Multiple Stakeholders
As a UN agency, the WHO consists solely of member states, which govern  
through the World Health Assembly (WHA) and the executive board. Yet  
nonstate actors have become major stakeholders in global health, often  
shifting their resources to new initiatives with governance structures  
reflecting their power. Known in international relations as forum  
shopping, stakeholders choose specific institutions to pursue their  
interests. In contrast to the WHO, representatives from civil society,  
the private sector, and foundations sit on the boards of the Global  
Fund and the GAVI Alliance. Even UN agencies such as the Joint United  
Nations Programme on HIV/AIDS engage civil society through advisory  

The WHO would be more effective by giving voice and representation to  
key stakeholders, including philanthropies, businesses, public/private  
partnerships, and civil society. While actively engaging with the  
private sector, the WHO should also set standards for and ensure  
compliance of key private partners such as the food, pharmaceutical,  
and biotechnology industries. At the same time, conflict-of-interest  
rules for expert committees and contractors require clarity and  

The director-general is taking a major step in proposing a global  
health forum, which would include regular multistakeholder meetings  
under the guidance of the WHA.2 The global health forum must afford  
stakeholders real voice and representation, effectively shaping the  
WHO's decisions. The WHA should also pass a resolution lowering the  
bar to official nongovernmental organization status. Meaningful  
stakeholder engagement would instill confidence and spark investment  
in the agency.

Improve Transparency, Performance, and Accountability
Good governance also requires clear objectives, transparent decision  
making, information dissemination, monitoring progress, and  
accountability. Stakeholders demand clarity on how their resources  
will achieve improved health outcomes as they shift toward results- 
based financing and performance-based measures. Yet a recent  
evaluation of multilateral organizations graded the WHO as weak on key  
parameters such as cost-consciousness, financial management, public  
disclosure, and fulfilling development objectives.4 To improve its  
standing, the WHO must make it easier for stakeholders to monitor  
achievements and demonstrate that activities effectively translate  
into better health outcomes.

Closer Oversight of Regions
The WHO's decentralized, regional structure poses a significant  
challenge in demonstrating results and delivering on priorities. The 6  
WHO regional offices are uniquely independent within the UN system,  
with full power over regional personnel, including appointment of  
country representatives. Regional committees meet annually to  
formulate policies, review the regional program budget, and monitor  
the WHO's collaborative activities for health. The WHA and the  
executive board formally approve decisions, but in practice do not  
provide tight policy and budgetary control.

The headquarters of the WHO should exercise more oversight and control  
over regional personnel and decision making. Minimally, the agency  
should fully disclose the funds held within each regional office and  
how regions meet health objectives, with monitoring and benchmarks of  
success. Even if decentralized decision making remains the norm, the  
WHO should apply the same yardstick across regions to assess  
efficiency and effectiveness.

Exert Legal Authority as a Rule-Making Body
The WHO's constitution grants the agency extraordinary rule-making  
powers, but the agency has promulgated only 2 major treaties in more  
than 60 years: the International Health Regulations and the Framework  
Convention on Tobacco Control. The WHO could take a more active role  
in regulating for the world's health on key issues, including  
counterfeit medicines, alcoholic beverages, food safety, and  
nutrition. It could be far more engaged and influential in  
international regimes with powerful health impacts such as trade,  
intellectual property, arms control, and climate change.

The agency could exert normative power through innovative treaties  
(eg, a Framework Convention on Global Health) or through soft power  
(eg, codes of practice) with strong incentives for compliance.5 The  
WHO must offer leadership for urgent challenges facing the global  
health system such as the need to set clear priorities, facilitate  
coherence among currently fragmented actors, and ensure fair burden  
sharing among states.

Ensure Predictable, Sustainable Financing
The WHO is financed through 2 main streams. First, member states  
pledge a specified proportion of total assessed contributions  
calculated according to each country's wealth and population. The WHA  
then unanimously approves a core budget. The second stream is through  
voluntary contributions often earmarked for specific diseases,  
sectors, or countries. The development assistance committee of the  
Organisation for Economic Co-operation and Development calls  
extrabudgetary funding “multi-bi” aid (ie, donors routing noncore  
funding allocated for specific purposes through multilateral agencies).6

The WHO's biennial budget more than doubled from US $1.6 billion in  
1998-1999 to US $4.2 billion in 2008-2009, but the agency has a dire  
budget deficit of US $300 million this year. More importantly, its  
extrabudgetary budget increased from 48.8% to 77.3% during that period. 
7 It is not sustainable to have voluntary funding represent nearly 80%  
of the agency's budget.

Moreover, extrabudgetary funding skews global health priorities.  
Assessed contributions are more aligned with the actual global burden  
of disease than extrabudgetary funding. For example, in 2008-2009, the  
WHO's extrabudgetary funding was primarily for infectious diseases  
(60%) and had negligible allocations for noncommunicable diseases  
(3.9%) and injuries (3.4%).7 Yet noncommunicable diseases account for  
62% of all deaths worldwide,8 and injuries account for 17% of the  
global burden of disease.9

The director-general's report proposes broadening the base for  
flexible, unearmarked funding by attracting new donors such as  
foundations, emerging economies, and the private sector.2 Although  
worthwhile, these stakeholders are unlikely to behave differently than  
traditional donors, and probably will prefer to control their funds  
through earmarks. The ideal solution would be for the WHA to set  
higher member state contributions. Member states must become genuine  
shareholders in WHO's future, act collectively, and refrain from  
exerting narrow political                      interests. Failing  
decisive WHA action, the WHO could consider charging overheads of 20%  
to 30% for voluntary contributions to supplement its core budget.  
Although overheads are a familiar model in academia, the WHO would  
have to guard against the risk that charges might drive donors toward  
other multilateral organizations.

Global Health Leadership
If the WHO is to hold its rightful place as the leader in global  
health governance, the organization must undergo fundamental reform.  
There is no substitute for the WHO, with its progressive constitution  
and global legitimacy. It is not likely that the same powers would be  
granted to an international organization if it were created today.  
Consequently, while remaining                      true to its  
normative and bold vision of health for all, the WHO must adapt to a  
new political climate, demonstrate global leadership, and deliver  

Author Information
	• Author Affiliations: Department of Politics and International  
Relations, University of Oxford, Oxford, England (Dr Sridhar); and  
O’Neill Institute for National and Global Health Law, Georgetown  
University Law Center, Washington, DC (Mr Gostin).
Corresponding Author: Lawrence O. Gostin, JD, Georgetown University  
Law Center, 600 New Jersey Ave NW, Washington, DC 20001 (gostin at law.georgetown.edu 

Published Online: March 29, 2011. doi:10.1001/jama.2011.418

Conflict of Interest Disclosures: All authors have completed and  
submitted the ICMJE Form for Disclosure of Potential Conflicts of  
Interest. Mr Gostin is director of the World Health Organization's  
Collaborating Center on Public Health Law and Human Rights. He also  
serves on the director-general's Ad hoc Advisory Committee on the  
World Health Organization and Global Health Governance.

Additional Contributions: We thank Eric A. Friedman, JD, and Emily A.  
Mok, DPhil, both O’Neill Institute Fellows, for valuable research and  
editing; neither of whom was compensated financially for these  

Previous Section

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Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International (KEI)
thiru at keionline.org

Tel: +41 22 791 6727
Mobile: +41 76 508 0997

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