Finance and Governance: Critical Challenges for the Next WHO Director-General

The 70th anniversary of the World Health Organization (WHO) is drawing near and so is the election of its next director-general, which will take place at a critical juncture. The 2008 global crisis uncovered the financial vulnerability of the agency, a product of the adoption in 1993 of a zero nominal growth policy, whereby the assessed contributions of member states have been frozen in absolute terms, failing to compensate even for the effects of inflation.¹ In addition, several countries regularly fall into arrears, even at such a modest level of contributions. Budgetary constraints are further aggravated by structural inefficiencies. As a result, the WHO budget has become dependent on voluntary donations, and its operational capacities are undermined. The dangerous consequences of this perfect storm became evident during the 2014 Ebola outbreaks, which exhibited WHO’s inability to perform in an effective way what has always been considered one of its quintessential roles: the deployment of instruments for controlling the international transfer of risks and ensuring a timely response to threats that spread across borders.²

Epidemiological crises have brought into focus the pressing need to improve the way in which the agency handles global health emergencies. At the same time, it has become increasingly clear that there is a broader reform agenda that WHO must pursue if it wants to remain relevant in an increasingly complex, diversified, and interconnected world.

The most important strategic imperative faced by the next director-general of WHO will be to reorganize the agency by functions. The global health system performs four essential functions:

1. Production of global public goods, such as research and development, standards and guidelines, and comparative evidence and analyses;

2. Management of externalities across borders (such as drug resistance, pandemics, and environmental pollutants) through surveillance systems and coordination for preparedness and response;

3. Mobilization of global solidarity through development financing, technical cooperation, and humanitarian assistance; and

4. Stewardship, which includes convening for negotiation and consensus building, priority setting, rule setting, evaluation for mutual accountability, and cross-sector health advocacy.³

Until now, the mix of functions has been unbalanced, since mobilization of global solidarity (specifically, technical cooperation) has been the predominant focus of WHO at the expense of the three other functions. Yet it is precisely those neglected functions that should be strengthened if WHO is to address its most critical challenges.

There is a growing perception among global health actors that finance and governance issues have limited WHO’s effectiveness and legitimacy. In terms of finance, the main restriction has been the erosion of the agency’s budget through the zero nominal growth policy adopted more than two decades ago, along with unpaid contributions by several member states and reluctance by most emerging economies to step up their contributions in line with their growing wealth and influence. The shortfall has been met through voluntary contributions provided mostly by a few member states and by nonstate actors such as global foundations, development banks, and multinational corporations. As long as they accounted for a relatively small share of the budget, these were welcome contributions to the work of the organization. At present, however, they account for more than three quarters of the budget⁴ and have become a response to the failure of member states to adequately fund their global health agency. Many fear that dependency on voluntary contributions erodes WHO’s leadership in setting the global health agenda.

On the governance side, the challenge faced by WHO is related to the performance of its functions. As previously mentioned, for a long time WHO has concentrated its activities on the provision of technical cooperation, which is a “supportive” function, at the expense of its “core” functions.⁵ Supportive functions are intended to assist national governments in fulfilling their responsibilities when they cannot do so independently; they supplement activities that are primarily the responsibility of nation-states. These functions can be performed by other actors of the global health system, such as multilateral development banks, nongovernmental organizations, or academic institutions. In contrast, core functions transcend the sovereignty of any one nation because they address cross-border risks or generate global public goods that serve all countries. WHO is particularly suited to develop these functions, which often require a global mandate. By neglecting its core functions, WHO has in many respects become one among many development agencies rather than fulfilling its irreplaceable role as the legitimate steward of international collective action for global health.

In addition to these challenges, there are also concerns around the process for electing the director-general of WHO, which is conducted via secret ballots. Although voting has traditionally been restricted to the 34 members of the Executive Committee, for the first time the final vote will now be taken to the full 193 member states that constitute the World Health Assembly.

Several informed observers have stressed the need for more transparency and public accountability, which requires abandoning secret voting procedures vulnerable to distorting influences or, even worse, to corruption.^6,7 Although most member state representatives have historically based their votes on the merits of the candidates, there is abundant anecdotal evidence of quid pro quos motivated by geopolitical interests that have little to do with advancing global health. At the extreme, the pursuit of personal gain has led some representatives to ignore the instructions of their respective governments in casting their votes.

Secret ballots were established to protect individual voters from the risk of coercion. But that logic does not apply when representatives vote on behalf of their constituents or the governments that appoint them. This is why voting is public in the vast majority of parliaments of the world. The same principle should apply to the United Nations and its specialized agencies such as WHO.

Despite all the challenges it faces, WHO has made and continues to make profound and long-lasting contributions to the well-being of humankind. WHO is an indispensable institution, and everyone interested in the advancement of health around the world has a responsibility to strengthen it. This is why the selection of the next director-general is so crucial and deserves the best possible process. If the global health community wants a strong, effective, transparent, accountable, and legitimate WHO, it should demand major changes in the financing and governance procedures of the organization, and in the way heads of United Nations agencies are elected.