The Covid-19 pandemic reveals the gap that exists between, on the one hand, the need for health cooperation on a global scale and the strong expectations in the WHO and, on the other hand, the limited means of action of the organization.
By: Yassine El Yattioui
Since the start of the Covid-19 pandemic, the World Health Organization (WHO) has played a leading role. At the center of the scene, the press conferences held almost daily, since January 22, 2020, by its Director General, Doctor Tedros Adhanom Ghebreyesus (of Ethiopian nationality), during which he distils recommendations to the states and urges them to mobilize. The WHO is, in fact, the United Nations specialized organization for health and one of its missions is the surveillance of infectious diseases and the coordination of the international response in the event of an epidemic.
Initially, attention was focused on the delay and inadequacies of national responses, and the WHO was hailed for reacting more quickly and forcefully than during the Ebola epidemic in western Africa in 2014. Nevertheless, international cooperation having quickly shown its limits, with states developing disparate strategies, the international organization began to look like a conductor whose musicians would not follow. Then the WHO came under attack, first by Taiwan and then the Trump administration, accusing it of being on China’s payroll and of delaying warning the rest of the world of the severity of the pandemic.
The spectacular announcement by the White House, on April 15, 2020, in the midst of the health crisis, of the suspension of American funding to the WHO (about 15% of its budget, the largest financial contribution), put the spotlight on the organization. While many countries such as Canada, France, Germany and South Africa have reaffirmed their support by emphasizing the “essential role” that the WHO has been playing and by calling not to weaken it, calls for reviewing the WHO's response to the pandemic and for organizational reform have increased. To better understand these issues, this article aims to contextualize the management of the pandemic by the WHO and the criticisms to which it is subject, by reviewing the role and means of action of the organization, as well as its reaction during previous epidemics.
Problematic: Faced with diplomatic, economic and national sovereignty constraints, what is the room for maneuver of the WHO in managing this Covid19 crisis?
1. Challenging global health security governanc
a. Fragmented international management
According to its Constitution, from 1948, the WHO is the directing and coordinating authority for international health. Its centrality in the international response to the current health crisis is nonetheless remarkable in view of the changes in global health governance in recent decades. Since the beginning of the 21st century, the field of global health has indeed experienced very strong development. Funding for international health actions, all donors combined, has increased from ten billion US dollars in 2000 to forty billion US dollars today, thereby quadrupling in just twenty years (Institute for Health Metrics and Evaluation, n.d.). However, within this harp increase only 7% are devoted to the WHO budget, which was, for 2019, 2.8 billion US dollars (which represents, by comparison, about a third of the annual budget of Paris public hospitals [APHP] and less than half of the annual budget of the Centers for Disease Control and Prevention [US Centers for Disease Control and Prevention, CDC]. This development in the field of global health has gone hand in hand with its fragmentation. New actors have emerged that give influence to funders: philanthropic foundations like the Bill and Melinda Gates Foundation (Truffinet, 2019), “vertical funds” which finance the fight against specific diseases (such as the Global Fund against AIDS, tuberculosis and malaria), public-private partnerships such as Gavi (Global Alliance for Vaccines and Immunization, Global Alliance for 'access to vaccines and immunization) or the Cepi (Coalition for Epidemic Preparedness Innovations, Coalition for innovation in epidemic preparedness).
Other intergovernmental organizations have also entered the field of global health since the end of the 20th century. This is the case of the World Bank, the largest financial contributor since the 1980s for health programs thanks to the loans it makes, as well as for the UN Security Council, which had declared the epidemics of HIV and of Ebola in West Africa as "threats to security and international peace".
But, during the Covid-19 pandemic, the WHO finds itself alone on the front line. As the World Bank is mobilizing to respond to the economic crisis, regarding the more specific response to the health crisis, the WTO finds itself entangled in the failure of its “pandemic catastrophe bonds.” These “bonds for pandemic catastrophes” have been developed since 2017 to free up financing in the event of an epidemic: by buying them, investors take the risk of no longer receiving interest or losing part of their capital in the event of an epidemic outbreak. On the other hand, as long as no epidemic occurs, they achieve a very high yield. However, it was not until the end of April 2020 to know the amount of funding that could finally be released: 195 million US dollars for 64 of the poorest countries on the planet, which is far too little and far too late.
b. The weight of the normativity of the organization
The specificity of WHO, within this diverse institutional landscape, is to be the only intergovernmental health organization with a universal vocation, which brings together 194 member states, developed and developing, on the principle that one state equals one voice. Created after World War II, it integrates the international health organizations that preceded it, including regional organizations such as the Pan American Sanitary Bureau. This explains the organization's specific governance structure: its headquarters are in Geneva, around 150 local office are in the member countries while the WTO also manages six regional offices which have broad autonomy, with regional directors elected by assemblies comprising the member states of a region, a feature often criticized for its ineffectiveness. At the headquarters in Geneva, we find the WHO secretariat, a technical and administrative body that implements the actions of the organization, headed by the Director General. He is elected by the member states sitting at the World Health Assembly and is supported in his work by the Executive Board of the organization made up of 34 member states, also elected by the World Health Assembly for three years. The universality of the organization gives it the legitimacy to carry out the global cooperation between all states, which is crucial in the event of a vaccination campaign or infectious disease surveillance, for example. If a state fails to do so, this will be problematic for everyone facing in this case a threat of a disease that have the capacity to spread globally.
The WHO has a very broad mission, which goes far beyond the fight against epidemics: it aims “to bring all peoples to the highest possible level of health.” It is therefore involved in a large number of areas: the fight against tobacco, malaria and polio, actions in favor of mental health, for universal health coverage, etc. This holistic approach to health is also relevant to the fight against epidemics, because it is prepared upstream in a multidimensional way, by building resilient national health systems, by guaranteeing access to care and treatment.
The WHO is above all a normative organization, that is to say that it establishes standards, recommendations, thanks to its expert capacities. It is not an operational organization that will directly carry out health actions in the field, which will be done by states or NGOs, for example, by guiding their actions thanks to the recommendations of the WHO and the data it collects and produces. In the case of the Covid-19 pandemic, the WHO published, on February 3, 2020, a regularly updated strategic response and preparation plan, as well as guidelines (how to deal with sick travelers, how to provide home care, etc.). This normative role has sometimes been fulfilled in an efficient manner (for example, with the now famous advice: "Tester, test, test” (3), sometimes not so much, when the fact of having to make recommendations valid for all countries, which implies being very careful in the face of an evolving situation, has blurred the message (as in the case of borders closure).
The organization also plays a coordinating and facilitating role for cooperation, for example, within the global influenza surveillance network, which includes 140 laboratories and is responsible for isolating influenza virus strains which are then transmitted every year to the pharmaceutical industry to manufacture vaccines. When in 2007, Indonesia announced its withdrawal from the network and its refusal to share its strains of H5N1 influenza, reigniting debates on the unfairness of a situation where, while developing countries provide a large part of the viruses, their access to vaccines and treatments, is then compromised when the prices set by pharmaceutical companies are too high, it is under the aegis of the WHO that diplomatic negotiations are carried out to find a solution (Aranzazu, 2013). The fact that WHO brings together developed and developing countries gives it a specific role to play in the issue of access to treatment, which is also found in the current Covid-19 pandemic. This diplomatic role of WHO as a facilitator of cooperation, often inconspicuous, “low noise,” is no less significant.
2. Between reforms and constraints
a. Too much economic affiliation with dependent nations
As an intergovernmental organization, the WHO is subject to a triple constraint. First, a political constraint: it must respect the sovereignty of states and only has the authority that they want to confer to it. For example, in order to send a mission to China to analyze the authorities’ response to the crisis, as it did in February 2020, the WHO had to first obtain permission from the Chinese government.
Second, a financial constraint: to the weakness of its annual budget (about 2.8 billion US dollars), we have to add the fact that about 80% of this budget is constituted of so-called voluntary contributions, which implies respecting donor priorities (member states and private organizations). The United States is the largest contributor to the WHO budget, with 15% in 2019 (with voluntary contributions directed primarily towards polio eradication and access to basic health services and nutrition). They are followed by the Bill and Melinda Gates Foundation (10%), the Gavi Alliance (8%), the United Kingdom (8%) and Germany (6%). In the event of an effective withdrawal of funding from the United States (which has become less likely due to the recent change of government), it is therefore a philanthropic foundation that would be the main funder of the WHO, which is not without its problems for an organization whose governance (and therefore the mechanisms of responsibility and control) is intergovernmental.
Finally, the WHO faces a geopolitical and diplomatic constraint: the power games between states have repercussions on the organization. From 1949 to 1955, at the start of the Cold War, eight countries of the Soviet bloc left the WHO, accusing it of promoting a Western form of health; in the 1980s, the Reagan administration cut and then threatened to cut US funding to the WHO, accusing it of playing an unacceptable regulatory role for putting in place an essential drug program.
During the current Covid-19 crisis, geopolitical tensions are crystallizing around China. First, regarding its relations with Taiwan, which Beijing considers to be an integral part of its territory and which, therefore, is not a member of the WHO (or of any other United Nations organization). Taiwan criticizes in particular its setting aside by the WHO, which avoids any reference to the Taiwanese response (a very rapid response, with few cases and deaths). In 2016, Taiwan lost its observer status at the WHO, granted in 2009, to China now opposing it due to the election of a new pro-independence president on the island. Taiwan is nevertheless integrated into international epidemic surveillance networks, more strongly since 2003; China, because of its criticized management of the SARS crisis, which had hit the island hard, had to allow it. But Taiwan would like to regain observer status at the WHO and is gathering state support in this regard (a dozen states, including the United States, have offered to invite Taiwan to the virtual World Health Assembly on May 18 and 19, 2020). Then, the Sino-US antagonism carries over to the organization. In a context of very strong criticism in the United States regarding the denial and unpreparedness with which the Trump administration has approached the epidemic, the former US president seeks not only to discard on the WHO, but also to stage its confrontation with China, which appears to be a key element of its strategy for the presidential election of November 2020.
b. A necessary structural reform, place for a more diplomatic axis of the WHO?
The analysis of the different tools available to WHO and the constraints that frame its action shed light on the organization's response to the Covid-19 epidemic and the way in which it is perceived. The criticism which carried the most was that of adopting an overly conciliatory attitude towards China, in particular of not having publicly denounced the lack of transparency and diligence of the Chinese government at the very beginning of the epidemic crisis. Indeed, the authoritarian nature of the Chinese regime, which has led in particular to the conviction of doctors for “circulation of rumors”, delayed the dissemination of information, in particular on the human-to-human transmission of the virus, between the end of December 2019 and beginning of January 2020 (The Associated Press, 2020).
This pragmatic, politically prudent approach is fairly standard on the part of an international intergovernmental organization, which seldom seeks confrontation with one of its member states. At the WHO, the only glaring case dates from the SARS crisis. In April 2003, after six months of frustration at China's uncooperative attitude, and as international media pressure mounted on the WHO, the organization’s executive director, Dr. Gro Harlem Brundtland, spoke out publicly criticized the Chinese authorities saying that “it would certainly have been useful if the WHO had been called for help more quickly” (Crampton, 2003). It can also be noted that the WHO is regularly attacked for its links with powerful actors. The organization was thus suspected of having undue relations with pharmaceutical companies, leading it to adopt directives to frame cooperation with the private sector. Prior to the focus on the role of China, which is all the more evident in a context of American disengagement from multilateral organizations, the WHO was criticized for its dependence, especially financial, on the United States. The same is true of the Bill and Melinda Gates Foundation, which the organization’s chief executive, Margaret Chan, invited to speak at the World Health Assembly in 2011.
The controversies surrounding the independence of the WHO from governments or private actors ultimately call for strengthening the autonomy of the organization. As after every epidemic, the WHO’s actions will be the subject of an evaluation, which may lead to more or less far-reaching reform. In 2003, after the SARS epidemic, the IHR was extensively revised, notably to clarify state obligations and extend the WHO’s sources of information to non-state actors. In 2014, after the Ebola epidemic, the WHO set up a health emergency management program, which has its own budget and staff. Proposals have already been made. Australian Prime Minister Scott Morrison, for example, wants to give the possibility to the WHO to send inspectors to investigate the health situation of a country, on the model of what the International Atomic Energy Agency is doing (IAEA). This would require that all member states are ready to accept the possibility of an inspection on their territory. The French foreign minister, Jean-Yves Le Drian, mentions the creation of a “health IPCC”, a high council for human and animal health, on the model of the Intergovernmental Panel on Climate Change (IPCC), to create more scientific consensus. For this consensus to play a role in the response to a health crisis, it seems essential that its production be linked to the universal organization that coordinates it.
In any case, the Covid-19 pandemic reveals the gap that exists between, on the one hand, the need for health cooperation on a global scale and the strong expectations in the WHO and, on the other hand, the limited means of action of the organization. If this gap is to be bridged in the long term, the reform will have to be comprehensive and also draw lessons from previous crises. Several avenues are possible. First, a reform of the financing of the organization, which must be more important and more stable (for example, with more regular contributions, not earmarked, or with a tax like that on plane tickets which, on the initiative of President Jacques Chirac, has been funding the Unitaid organization since 2006). Second, a reform of the governance of WHO, which could include a review of the regional structure of the organization, inclusion of civil society, accountability of member states in the event of an epidemic (currently everything depends on the organization's secretariat and its Director-General, while the two organs on which the member states sit, the World Health Assembly and the Executive Board, are invisible in crisis management). Third, a strengthening of its power of constraint regarding states, for example, within the framework of the IHR, to intervene without waiting for states in the event of the emergence of an infectious disease or so that civil society actors (launchers alert or others) can be taken into further consideration. Fourth, the strengthening of its expertise capacities, to take into account situations of scientific uncertainty. All these avenues are complementary and should be pursued simultaneously in order to strengthen the organization’s autonomy from donors, its independence from members and its legitimacy as a normative organization.
Aranzazu, A. (2013). Le réseau mondial de surveillance de la grippe de l’OMS. Modalités de circulation des souches virales, des savoirs et des techniques, 1947-2007. Sciences sociales et santé, 31(4), 41-64.
Crampoton, T. (2003, April 7). WHO criticizes China over handling of mystery disease. The New York Times. https://www.nytimes.com/2003/04/07/international/asia/who-criticizes-china-over-handling-of-mystery-disease.html
Institute for Health Metrics and Evaluation. (n.d.). Flows of global health financing [Data set]. https://vizhub.healthdata.org/fgh/
The Associated Press. (2020, April 15). China didn’t warn public of likely pandemic for 6 key days. https://apnews.com/article/68a9e1b91de4ffc166acd6012d82c2f9
 Doctoral student in Political Science and International Relations at the University of Salamanca (Spain). MA in International Relations from University of Lyon 3 (France) and MA in Political Science from University of Lyon 2 (France).
 WHO recommendation following the example of South Korea's crisis management in identifying the population contaminated by Covid-19 and the strategy to be put in place.
 The WHO's total budget is available through this link: http://open.who.int/2018-19/contributors/contributor