Should the World Health Organization's leadership be enhanced?

Dear Editor,

Since the first disclosures of coronavirus cases in late 2019, the World Health Organization (WHO) has been at the heart of many discussions regarding its leadership and legitimacy. The WHO's recommendations and guidelines for Member States to counter the pandemic have come under scrutiny from the media, experts, or public and political representatives - sometimes with strong criticism (e.g., regarding information sharing, timelines for action, or lack of authority) [1], [2]. As an international health crisis, this pandemic was an opportunity to test the impact of the WHO and to further reveal its strengths and weaknesses. It is therefore essential to learn from this global crisis to improve global health governance and rethink the leadership of the WHO. In this perspective, an international conference was organized on March 24, 20221 , around the core question “Is the WHO healthy?”. Based on the discussions from this conference, we found that a key question remains open and deserves international attention: should the WHO's leadership be enhanced, how and why?

Increasing the leadership of the WHO may seem like the only possible way to improve global health governance, as it now aims to “provid[e] political leadership, negotiat[e] international disputes, and coordinat[e] technical and normative guidance in the pandemic response”[3, p. 1618]. However, through the interventions of the speakers, at least three arguments support the idea that it is not necessarily relevant to increase the leadership of the WHO:

• •it is not necessary to increase its impact because the WHO is already sufficiently effective;
• •it is not possible to increase this impact because in any case the WHO is confronted with the sovereignty of States;
• •and it is not desirable to increase this impact because it is not in line with the mission of the WHO.

First, one may say that the WHO is already sufficiently effective. During the conference, several success stories were raised regarding the WHO's impact during the pandemic, which could be extended to its leadership in general: the WHO provided moral clarity to Member States according to Peter Singer, Special Advisor to the WHO's Director-General, and allowed for a high level of diplomacy and negotiations as mentioned by Michael Pearson, Director General of the Office of International Affairs of the Public Health Agency of Canada. Almost all speakers acknowledged the success of the WHO's mission of coordination of global health during the pandemic. Richard Massé, Former Québec public health official, recalled that, historically, the WHO has also succeeded in raising awareness that health is not only an individual responsibility but also a responsibility of States. Professor Catherine Régis, presenting a recent empirical study, highlighted that contrary to what has sometimes been portrayed in the news or by political leaders worldwide, States remained overall relatively convergent with the WHO's recommendations during the pandemic (the study was based on mask wearing and border control measures) [4]. This goes against the general assertion that WHO is irrelevant or ineffective. Thus, perhaps the mission of the WHO is already fulfilled, and the effort to overcome the coming global health challenges lies elsewhere than in simply enhancing the WHO's leadership2 .

Second, the WHO and its norms often confront with the States’ sovereignty - which can undermine any effort to increase the leadership of the organization. As Massé said, the WHO can only become stronger if Member States decide to adhere to its guidelines and accept its authority. State sovereignty has played a large role in increasing disparities during the pandemic: a form of “structural injustice”, according to Professor Ryoa Chung. Disparities in power between States are, at some point, perpetuated within the WHO itself (due to the unequal contribution of States to the funding of the WHO) and thus lead to questions about the need to use other forms of power to improve global health governance. For example, the WHO's COVAX initiative, whose primary goal was to address the issues of unequal access to vaccines [6], has created a race for vaccines in which richer countries have acquired many vaccines at the expense of poorer ones. One of the consequences of this guidelines meant for sharing is the delivery of soon-to-expire vaccines in several low- and middle-income countries [7] and did not prevent the waste of unused, expired doses in high-income countries such as in Europe [8]. Hence, increasing the WHO's leadership could then lead to a hazardous power struggle. As acknowledged by Louise Frechette, former Deputy Secretary-General of the United Nations, “the worst that could happen to the WHO is that it becomes another battleground for powerful nations. If everything is seen as the victory of the one or the defeat of the other, it will be disastrous” (free translation). For Chung, it is the current design of international law that determines the aforementioned structural injustices, which both create and perpetuate serious global problems - meaning that we should think out of the box, and we must not close ourselves off to other options for global health governance.

The third argument is related to the desirability of increasing the impact of the WHO because its primary mission is not in line with more leadership. This last argument echoes the question (far from being new)3 of whether more soft law or hard law should be produced - including by the WHO [10]. From a soft advisory role to a driving force of international health law, a plethora of missions can be attributed to the WHO, without there being a consensus on which is the most desirable. Some speakers advocate for the need of international binding norms (hard law) to enhance the WHO's leadership, especially to tackle the issue of inequity among Member States, which is one of the most important challenges of the pandemic according to Singer. For Massé, coercion is essential where there is no time for negotiations, as in the context of a global health crisis. In his view, the adoption of binding norms is essential to ensure the sharing of science, expertise, and technologies among Member States, as without constraint, such sharing would be unlikely to occur. Yet, it should be mentioned that coercion in international health law is often more theoretical than a reality. Moreover, according to Côme Bommier, Hematologist and Researcher, the WHO should not go beyond a “super advisor” role and issue more binding norms, because the conditions for legitimate global governance are not met4 . Thus, the WHO's leadership should be strictly limited to influencing and educating Member States as well as producing soft law. For Pearson, the strength of the WHO during the pandemic was precisely that of the soft law one, namely: early warning and good communication to ensure appropriate understanding of the virus operating mode. A study conducted by Régis et al. during the first wave of the pandemic reveals that the binding nature of the norms adopted by the WHO does not necessarily imply greater compliance by Members States than non-binding ones [4]. According to some of these views, it is thus not necessarily desirable to enhance the WHO's leadership more than what currently exists.

Should the WHO be restricted to coordinating global health efforts? Should it expand its functions to include capacity building and training? Should it be the leader in global health law and the main producer of international norms whether they are binding or not? At a time when an international treaty on pandemics is being discussed [11], to undertake these questions is of great importance. As a “learning organization” (to use the words of Singer), the WHO should draw lessons from the recent global health crisis to better frame its future leadership, which is all the more important in the context of the “One Health” wave, whose challenges will extend the scope of the WHO's influence to achieve better health for everyone, everywhere.

Disclosure of interest

The authors declare that they have no competing interest.

Financial support

This work was supported by the Canadian Social sciences and humanities research councils (SSHRC) [Insight Grant number 435-2020-0470]; the Canada Research Chair in Health Law and Policy; and the Stellari Funds. NV is funded by the International Observatory on the Societal Impacts of AI and Digital Technology (OBVIA – Fonds de recherche du Québec), Montreal, Canada.

Contributors

All authors brainstormed, shared ideas, and conducted research for the article. NV organized the arguments in the first outline, wrote several sections of text and managed the various revisions. GF wrote several sections and revised the overall text several times. CR wrote several sections and revised the overall text several times, and supervised the research and writing. All authors have approved the final version of this article.