This post was originally published in May 2020.
The 73rd World Health Assembly was held in ‘virtual’ session this week amidst continuing controversy about the role and conduct of its convening body, the World Health Organisation. One informed commentator summed up some of the received wisdom on the matter, “If the World Health Organization wants to maintain its legitimacy on the world stage, it must now answer some tough questions about the extent it has kowtowed to China during the coronavirus pandemic”. Such a view is a depressing reflection of a trend in international relations that has been growing strength for some time now, and that has been brought into sharp focus by the SARS-CoV-2 crisis.
As with all agencies, funds, and programmes of the United Nations, effectiveness is subject to the support of member nations for relevant strategy, approach, and activity. Whilst UN agencies can justifiably be held to account for their efficiency, effect is not always entirely in their gift unless the international community takes an active interest. The current pressure under which the WHO is trying to respond to the SARS-CoV-2 pandemic is therefore largely unfair, given that over the last decade at least, support for the international regulatory framework has diminished to the point of irrelevance. It is simply no use crying that an organisation has not demonstrated its fitness for purpose now that its services are required. In fact, much of the fault lies with the way in which member nations have taken little notice of its interests in preparing for such a situation.
Over recent years the most influential nation states in the world have provided increasingly less support for UN specialised agencies, funds, and programmes. They have instead preferred to construct alternative coalitions and partnerships to address a range of global challenges in smaller fora that offer the perception of increased consensus and common objectives. In an era of globalisation it is a surprise to see that there is less global engagement through the most obvious vehicle for such mediation and interaction, designed and established at the end of the Second World War. Parallel structures are now the norm.
The roots of this trend lie perhaps with the perception that the end of the Cold War brought about a unipolar international system which diminished the need for a rules based international order. Capitalism, led by the United States, had triumphed and brought about ‘the end of history’. With much acclamation Francis Fukuyama forecast the remaking of the New World Order, based on what has been described by critics as a mischaracterisation of the international environment. Be that as it may, Fukuyama’s views were arguably interpreted widely as an acceptance that the US and its allies were able to dictate the agenda.
At the 2004 annual dinner of the American Enterprise Institute for Public Policy Research when receiving an award from Vice President Dick Cheney prominent journalist Charles Krauthammer described the advent of a unipolar era under uncontested US hegemony. That has proven an incorrect, and even a dangerous analysis. But Krauthammer also warned against consequent isolationism, describing it as ‘morally obsolete and politically bankrupt’. Unfortunately, the global response to the threat of the current pandemic has been significantly more isolationist than integrated and mutually supportive. This should be no surprise. Since 2004 the leading global players have become increasingly self-interested and have particularly withdrawn in opposition to or exasperation with the UN. The situation currently affecting the WHO is in large part because of this behaviour over the last dozen years or so.
To oversimplify, the problem is one of expectations. If there is not consensus at the start of an endeavour about what is expected to be delivered or achieved, then all that ensues is a series of arguments about what is to be done. Everyone likes detail. It is immediate, in the present, and offers the possibility of an instant fix. Political points can be scored much more easily in an argument about details than about policy and direction. Evidence can be carefully selected and presented to add weight to opinion about what should be done, unconstrained by the need to present any evidence about whether or not such an activity is likely to have a positive longer-term effect. As any Balanced Scorecard practitioner can attest, ‘lag’ metrics are much easier to identify and collate than ‘lead’ indicators. Arguments rooted in the here and now are much more effective and a longer term, more considered view seldom makes a greater splash.
As far as the WHO is concerned, the problem is that criticism assumes that the agency has far greater executive authority than was ever invested in it by UN member nations. Because, under the mandate of the UN, the agency has no absolute authority to investigate issues under sovereign jurisdiction, its freedom of action is constrained by its political relationships with individual nation states. President Trump has heavily criticised the WHO for trying to maintain good relations with China. If it wished to remain engaged with Chinese authorities, the WHO had no choice but to do so. And if access was being denied or if more force was thought to be required to investigate initial concerns about the SARS-CoV-2 outbreak then member states would have needed to underwrite the necessary mandate and legitimacy. They did not do so.
On its website, the WHO declares that its worldwide mandate is to ‘promote health, keep the world safe, and serve the vulnerable’. Lofty goals and laudable, but very generic. This reflects an apparent mismatch in expectations between what the WHO is intended to do, what it is funded and resourced to do, and ultimately what it actually does. In an article published in the Journal of the Royal Society in April 2017 this issue was cited as the main driver for criticism of the WHO performance in response to the Ebola crisis of 2014. In her article, Clare Wenham noted ‘the discrepancy between what the global community expects the WHO to do in a health emergency and what it is able to do with its financial and organisational constraints’. It would be reasonable to ask what the international community actually did to address that fundamental issue and better align the WHO’s capability with requirements and expectations before it started to complain about the WHO’s performance in the current crisis. The article concluded:
“The challenges that the WHO faces from financing and organizational divisions will not be overcome with this new programme [the Health Emergencies Programme], and therefore for the WHO to be in a position to actually respond to an outbreak, these fundamental structural concerns will need to be addressed comprehensively to allow the WHO the resources and power to perform the role that the global community expects”.
Article 2(a) of the WHO’s constitution authorises it ‘to act as the directing and co-ordinating authority on international health work’. Yet the assumption has always been that such leadership in global health will be in routine and take the form of shaping research and knowledge, setting healthcare standards, providing technical support, and generally monitoring global health. In 2015 Colin McInnes suggested in International Affairs that the Ebola crisis had shown that the authority of the WHO was under threat. Authority, he states, is different from legitimacy. Previously based on what he described as the ‘expert’ and ‘delegated’ models, McInnes argued that it must increase its authority through developing the operational capacity to act in major health crises:
“Despite a number of innovations since the millennium, including an improved disease surveillance and response system through the Global Outbreak Alert and Response Network and revisions to the International Health Regulations (IHRs), the WHO had not been provided with an operational capacity to respond to a major disease outbreak. Nor was the WHO's organizational culture capable of accepting such a role”.
In their 2010 work, Who Governs the Globe? Avant, Finnemore, and Sell describe three forms of authority (expert, delegated, and capability) which, if ‘not fulfilled, leads to a lack of trust, potentially undermining legitimacy’. Further:
“These different forms of authority are not mutually exclusive, and a governor may possess multiple authorities; but when it does so, it runs the risk of conflict between different expectations of behaviour. This may result in a variety of outcomes, ranging from institutional paralysis to the prioritization of one form of authority over another or others. These outcomes in turn affect the legitimacy of governors, potentially creating pressure for change in either a governor's authority, or in who the governors are”.
McInnes comments that this ‘establishes a means of understanding how the nature of the WHO may be changing… The wider expectation of action during the [Ebola] crisis created a tension, which undermined trust in the WHO and threatened its legitimacy’. In its own report following the Ebola crisis, the WHO also argued for a shift in the balance of its authority from ‘expert’ and ‘delegated’ in routine to ‘capability’ in emergency. This reflected its recognition of the likelihood of infectious diseases spreading further and more rapidly in future and that they would become more common because of changes in our social and environmental systems.
In 2015 the WHO established a contingency fund for emergencies. In the last five years the fund has received over $150m in voluntary contributions from 23 member states, the top five of whom (Germany, Japan, UK, Netherlands, and Sweden) all contributed sums over $10m each (80% of the total commitments) in addition to the assessed contributions to the WHO to which they are obligated by membership. The US has not contributed to the CFE although in 2018/19 it committed an additional $600m in voluntary contributions and has been WHO’s largest donor over time. Following President Trump’s decision last month to withhold core funding, it is also important to note that five nations (Brazil, China, Germany, Japan, and USA) have not yet paid their assessed contributions for 2020, together amounting to $341m or 68% of the WHO fixed annual operating budget (which doesn’t include voluntary contributions). Four of these countries are in the top five performing world economies by GDP, with Brazil rated 9th.
At the moment the world needs the WHO to act as it perceives itself equipped and resourced to do, as an expert with delegated authority to oversee and coordinate. Much more is needed to be known about the virus and the way it behaves, in order to inform risk management responses that balance the health threat with the negative societal and economic impact (and the wider health impact) of the response measures themselves. It is simply shameful that the world’s media’s preferred provider of statistics on the spread of the virus is a US based university and not the WHO. That the WHO is not at the centre of collating information about the characteristics of spread and transmission is woeful. Statistics that are available are inconsistent and unreliable, making clear that even in routine, the WHO does not have the resident resources in each country to accurately support the tracking and development of transmittable disease. An excellent resource from the University of Oxford aims to ‘track and compare policy response around the world, rigorously and consistently’. Why is the WHO not at the centre of this type of valuable research?
Despite a considerable number of indications that it needed to do so, in recent years the international community has failed to engage with the WHO to confirm expectations about its role or to encourage and resource change. Amidst considerable criticism about its activity and behaviour early in the crisis, the WHO is now conspicuous by its absence from global news coverage. Perhaps understandably it is suffering from a crisis of confidence, but perhaps also it has now confused its authority and lost its legitimacy. But both these are external perceptions of an organisation and as the WHO acts on behalf of its member nations, the curious cyclical relationship means that perceptions of authority and legitimacy are reducing its credibility in the eyes of its own membership. In turn member nations are failing to act to restore authority and legitimacy by expecting from the WHO what it was not organised or resourced to provide.
A growing number of commentators are now lamenting the lack of a global response to the SARS-CoV-2 crisis. A global crisis requires a global response. That international organisations are being criticised for not being sufficiently capable to provide focus and coordination for such a response is not their fault alone. It is the fault of the international community in not engaging sufficiently to develop and support those organisations in a changing world. The community of nations, particularly its influential leading economies, have not so much deliberately disengaged in an increasing spirit of isolationism, but allowed the international regulatory framework to wither on the vine of political points-scoring, antipathy, and strategic apathy. The US has led the way in all respects. The WHO should not have to show that it 'wants to maintain legitimacy'. It is for the nations of the world to commit to the provision of resources and support sufficient for it to do so.
Forecasts abound about the ‘new world order’ after the virus. Perhaps we should instead be thinking about adjustments to the ‘old world order’ that mean we’re not just doing the right things, but doing the right things right. Critically, we should start with aligning expectations better than we have to date otherwise we will continue to have the international organisations we deserve.
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