World Health Organization Reform—A Normative or an Operational Organization?

In a rapidly changing world, it is not unusual for a major institution to review its mission, whether its organizational structures are appropriate for its purpose, and how it works with major players to advance areas of mutual interest. Since the mid-1990s, the World Health Organization (WHO) has had reform agendas, yet rarely have these yielded the anticipated outcomes. The process of selecting a new WHO director-general has started. I summarize past reform efforts to highlight how intractable obstacles beset change and propose recommendations on the extent to which WHO functions as a normative or an operational institution, questions that should be addressed by future director-general candidates.

Three key WHO reform initiatives were initiated by directors-general over the last two decades. Hiroshi Nakajima (Director-General 1988–1998) was elected after Halfdan Mahler (Director-General 1973–1988) to spearhead substantial revisions to WHO’s Constitution. He came under pressure from governments to respond to the Ebola and infectious disease outbreaks and the sentiment that WHO was not engaging with new initiatives to address global research, HIV/AIDS, and vaccines.¹ Gro Harlem Brundtland (Director-General 1998–2003) was elected to “make a difference” in measurable outcomes and undertook substantive restructuring of key programs since WHO’s establishment in 1946. Brundtland focused on reducing the influence of governments in WHO’s work and expanding public–private partnerships.² Margaret Chan (Director-General 2007–2017) was elected after Lee Jong-wook’s (Director-General 2003–2006) premature death while in office and responded to the WHO’s inability to address global pandemics. Nakajima, Brundtland, and Chan failed to tackle the reforms needed to ensure that WHO can direct and lead health programs within the United Nations (UN) system.

Since WHO’s establishment, there have been debates about its core mission and objectives.³ Governments have called for trimming the list of objectives in WHO’s Constitution.⁴ Disagreement continues about whether WHO is a normative organization that develops global norms and standards (e.g., international health regulations, the WHO Framework Convention on Tobacco Control, the essential drug list, growth standards for children, and the International Classification of Diseases), leads and coordinates global health research, and acts as a powerful voice for health in development debates; an operational organization that eradicates diseases, controls pandemics, tackles humanitarian crises, and supports health systems development in the least developed countries; or some combination of the two. To date, success has been related mainly to the development of norms and standards, selected advocacy for neglected issues, mental health, and smallpox eradication. Other agencies within the UN, scientific community, and nongovernmental organizational world lead global health research, trade, health systems development, humanitarian support, and aspects of infectious disease control. That should allow WHO to focus on its comparative advantage, success records, and established relationships.

Critiques of Nakajima and Chan have been harsh and blunt. Concern about their ability to provide leadership during infectious disease crises has led the UN, national bodies, and global foundations to establish governance structures that engage WHO, although not as the lead agency. WHO’s inability to target the major risk factors that underlie the global burden of disease rarely receives criticism, despite the consequences for global health.

Brundtland’s reforms were positively received and led to new investments in global health. Multistakeholder partnerships were funded with substantive budgets, including The Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunizations; and the Global Alliance for Improved Nutrition. These partnerships addressed issues in ways WHO acting alone could not. Areas that had been neglected since WHO’s establishment, including noncommunicable diseases, injury control, and tobacco, received visibility and modest increases in funding. For the first time, estimates of the burden of disease and risk were used in decision-making.

After Mahler’s leadership, which led to the Alma-Ata Declaration of 1978 and the launch of primary health care, Nakajima lost ground for WHO in its global effect and influence. Brundtland is credited with placing WHO and global health at the highest level of the development agenda. Chan was criticized for letting that slip when the UN, the World Economic Forum, and new players embraced health in development. The latest reforms agreed to during the May 2016 World Health Assembly may restore her image but only if they lead to progress.

All three WHO reform efforts by Director-Generals Nakajima, Brundtland, and Chan suffered from realities embedded in the structure of WHO’s Constitution. These constitutional structures must be changed by a new director-general if future reform is to endure.

First, commentators have had concern that WHO’s regional arrangements would undermine progress since 1946. These have not been seriously revisited since 1946, and any director-general is left with weak leverage to build one strong, coherent organization. The logic of a regional director with dual allegiance to WHO’s director-general and his or her regional countries, combined with a regional office and a physical location, is crying out for review and modification. Current regional arrangements waste resources, encourage political indecisiveness, and impede pandemic control. A future director-general must embrace these to address current and future needs. This involves embracing the power of innovative technologies capable of bridging distance, language, and time to implement twenty-first century organizational and management capabilities.

Second, WHO’s interactions with nonstate partners (a term that is unacceptably derogatory by using a blanket label that fails to acknowledge heterogeneity among partners) demand reform beyond the 2016 WHO Framework of Engagement With Non-State Actors (FENSA) resolution. Although Brundtland opened communications with companies and nongovernmental organizations to tap their knowledge, Chan has warned about these engagements in statements that are hostile to the industry.⁵ FENSA suggests that progress may happen but needs a director-general who adapts his or her tone and outreach to the spirit of the resolution. FENSA is written primarily to limit conflicts with nonstate actor interactions as opposed to the language of the Addis Ababa, Ethiopia, Third International Conference on Financing for Development; the UN Sustainable Development Goals; and the mission of the UN Global Compact.⁶ These documents have a vision that development goals can be addressed when players join forces.

Climate change, political instability and associated humanitarian crises, and the threat of infections will challenge global health systems. Crises undermine long-term norms, but it is the latter that underpin science-based progress and is where WHO is uniquely placed to lead. This decision is long overdue but may be undermined by the World Health Assembly’s decision to establish the Health Emergencies Programme with explicit operational responsibilities.⁷ That may draw resources into permanent firefighting at the cost of deliberative norm-setting functions. A future director-general must consider how to enhance WHO’s normative and advocacy roles without being pulled into every health crisis.

A future director-general needs to lead discussions on WHO’s role in a world that is so different from 1946. Global health has become the business of many nongovernmental organizations, private foundations, corporations, and academic groups; the World Bank; and other UN bodies. This can be beneficial for global health if role clarification were to emerge and if WHO’s central role as the global health conductor of an emerging health orchestra were to be reinstated. That requires individual leadership by those who can work with diverse players. It also takes a director-general who will lead governments to tackle norms, standards, and advocacy and, in doing so, spin off operational functions to other organizations within the UN and nongovernmental organizational world that are better qualified to execute them.