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Can the World Health Organization lead? Do we want it to?

- August 8, 2014

World Health Organization (WHO) Director-General Margaret Chan addresses the media after a two-day meeting of its emergency committee on Ebola, in Geneva, August 8, 2014. West Africa’s raging epidemic of Ebola virus is an “extraordinary event” and now constitutes an international health risk, the WHO said on Friday. REUTERS/Pierre Albouy
On Friday, the World Health Organization (WHO) officially declared the current Ebola outbreak a “public health emergency of international concern.” Ebola is only the third disease to receive this designation, underscoring its importance. This declaration means that the world is facing a serious health emergency that requires a “coordinated international response” that puts WHO front and center at facilitating the world’s response. This should be the time for WHO to shine.
While it’s too early to know exactly what effect this designation will have, WHO’s track record on responding to Ebola doesn’t necessarily inspire confidence. Dr. Bart Janssens, the Director of Operations for Medicins Sans Frontieres/Doctors Without Borders, responded to the declaration by saying that “statements won’t save lives” and decried the slow response to the outbreak. Dr. David Heymann, who led WHO’s response to SARS, wondered whether the declaration would make any difference. WHO announced that it needs $71 million to fight the outbreak (though its actual budget may be closer to $100 million), but that is overshadowed by the World Bank and African Development Bank together making approximately $250 million available to fight the disease. Instead of being at the forefront of responding to Ebola, WHO looks reactive and uncertain.
According to its constitution, WHO is “the directing and co-ordinating authority on international health work.” The Ebola outbreak, though, highlights the difficulties facing WHO as it attempts to carry out that function. WHO has made some missteps in responding to Ebola, but it also faces serious structural constraints that undermine its ability to uphold its mission.
Let’s be clear: WHO has not responded to Ebola as swiftly as it should have. Under the International Health Regulations, any human cases of Ebola must be reported to WHO within 24 hours, which should then trigger a response from the organization. This did not happen. WHO received its first report about Ebola cases in Guinea on March 22, but it took more than three months for it to convene a meeting of regional health ministers or open a regional coordination center. A WHO spokeperson admitted that the outbreak “wasn’t taken seriously” at first. This tardiness may have arisen from the criticism WHO received for designating the swine flu (H1N1) pandemic a public health emergency of international concern in 2009—the first time WHO had ever done so. The organization was chastized for being too quick to make the designation, operating in secrecy, and including scientists who had worked with vaccine manufacturers on its advisory board.
WHO deserves criticism for its tardiness, but we also need to understand the constraints placed on it. For an international organization tasked with overseeing global responses to health emergencies, WHO is woefully under-resourced. Over the past two years, the organization has seen its budget decrease by 12 percent and cut more than 300 jobs. The current budget saw cuts to WHO’s outbreak and crisis response of more than 50 percent from the previous budget, from $469 million in 2012-13 to $228 million for 2014-15. This is the very budget line that the organization needs to rely upon in order to respond to Ebola. After it announced it needed $71 million to implement its Ebola response plan, WHO now has to hope member-states or private organizations agree to contribute.
WHO’s budget is further complicated by its two revenue streams. Like any other UN organization, WHO assesses its members dues. The organization has full control over what it wants to do with these funds, known as regular budgetary funds. Every May, WHO convenes all of its member states in Geneva for the World Health Assembly, where the delegates decide how to allocate the regular budgetary funds. The other revenue stream comes from voluntary donations given by member states and private organizations for specific purposes. WHO therefore has no control over how it will spend that money, known as extrabudgetary funds; their use is dictated by the donor. Unfortunately for WHO, member-states have consistently resisted efforts to increase their assessed dues. This means that its budget is increasingly reliant on the extrabudgetary funds that it cannot allocate as it sees fit. For 2014-15, extrabudgetary funds make up 77 percent of WHO’s budget. Donor interests do not necessarily align with WHO’s priorities, hamstringing its ability to respond to crises. Because WHO has direct control over so little of its budget, it simply can’t shift money around for its Ebola response; it has to beg for additional funds.
With its limited budget, WHO itself cannot really provide funds directly to governments. Indeed, the World Bank is now the largest funder of global health projects, significantly outstripping WHO. By the same token, it does not have large numbers of personnel that it can deploy to assist the overburdened health clinics in Ebola-affected areas. Instead, it must work with governmental agencies like the Centers for Disease Control and Prevention and private organizations like Samaritan’s Purse and MSF to provide the nurses, doctors, and technicians that can augment local capabilities. These groups have highly skilled personnel, and they should be thanked for their willingness to go into dangerous situations, but having to rely on outside groups necessarily slows down how quickly WHO can respond.
The Ebola outbreak is exposing the weaknesses in the World Health Organization and its ability to be a leader in responding to global health issues, but many of these weaknesses result from constraints imposed by member states. This raises the question of whether WHO can actually fulfill its stated mission. Steven Hoffman and John-Arne Rottingen argue that the organization is hopelessly caught between its political and technical roles, so WHO should be split in two along those lines. Kelley Lee and Tikki Pang assert that global health is so all-encompassing that it cannot be handled by one single organization, while Lawrence Gostin has called for a Framework Convention on Global Health that would legally obligate states and the international community to meet certain health standards.
The current Ebola outbreak in West Africa has caused more illness and death than any previous one, and we all hope that the World Health Organization is able to quickly and effectively coordinate a response to the current Ebola outbreak. We must remember, though, that many of WHO’s shortcomings in responding to this outbreak are the result of limitations placed on the organization. If we want a WHO that can respond more quickly and with more resources, the international community has to be willing to support such an organization.
Jeremy Youde is an associate professor of political science at the University of Minnesota Duluth. His most recent book, Global Health Governance, examines the governmental and non-governmental actors involved in health issues. Follow him on Twitter: @jeremyyoude.