The World Health Organization and the Response to the COVID-19 Pandemic: How the WHO failed and why it doesn’t matter
Elizabeth Good
Northwestern University
MAY 2021
As COVID-19 remade the world in 2020, the World Health Organization (WHO) came to occupy center-stage as the global institution with a mandate to deal with pandemics. How did it perform? In this paper — published as part of the Global Governance in the Age of COVID research project at the Weinberg College Center for International and Area Studies, Northwestern University — Elizabeth Good, Project Assistant for Global Governance in the Age of COVID, examines the WHO’s mixed results in response to COVID-19: some success, some failure, and many lessons on the limits of governments and global governance.
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With 3.5 million dead and 160 million confirmed cases across 223 countries and territories, containing the novel coronavirus clearly exceeded the capabilities of the World Health Organization (WHO). Despite methodical preparation and the Organization’s use of every tool and preventative measure at its disposal, the WHO was unable to live up to its self-professed goals of controlling and preventing pandemics. This article examines how the world’s singular institution for managing global pandemics failed. It traces how the Organization’s internal bureaucratic structure combined with the inescapable limitations of the international system guaranteed this result. By tracing the process of organizational failure at the WHO, I show that no international organization built along traditional lines would have succeeded where the WHO failed. This has large implications for all global-problem solving that rests on the traditional model of inter-state inter-governmental organizations. The WHO’s experience with COVID-19 shows the dangerous mismatch between organizational form, substantive problems, and expectations and raises some doubts about the standard model of global governance.
I: Introduction
The COVID-19 pandemic has claimed the lives of over 3.5 million people worldwide with over 150 million confirmed cases in 223 countries and territories.[1] The international scale of harm and the persistence of the virus, which is believed to have originated late 2019, was a natural call to action for the World Health Organization (WHO). Although COVID-19 appears to be a global problem best coordinated by an International Organization mandated to respond to pandemics, world leaders have been liberal with their criticism of the WHO’s response. Throughout 2020, the US was the most vocal opponent and went as far as to signal withdrawal from the Organization altogether.[2] The US was not alone; over 100 countries demanded an independent investigation into the WHO’s response to the virus, widely citing the Organization’s relationship with China as cause for concern.[3] While it is possible that leaders denounced the WHO as means of redirecting blame away from their own inability to contain the virus, it is difficult to convince everyday individuals that the WHO is entirely free from fault.
Between 2020 and 2021, people grieved loved ones, lost employment, and were confined by lockdowns and travel restrictions. From a civilian perspective, it is difficult to argue against the idea that the WHO clearly failed to mitigate COVID-19 based on the death toll, economic impact, and longevity of the crisis. However, there is a grave distinction between what International Organizations are expected to do by the general public or world leaders in times of crisis and what International Organizations are actually capable of doing. Therefore, while individuals may be quick to label the WHO’s response a failure, it is important to conceptualize success or failure using the Organization’s own benchmarks. The WHO methodically prepared for epidemics and pandemics and successfully implemented every preventative measure the organization had at its disposal. Despite this, the WHO was ultimately unable to abide by its own organizational mandate to control and prevent pandemics.[4]
Rather than focusing on whether the Organization failed, I choose to take the WHO’s failure as a given. I support this assumption by referring to the corresponding economic decline - the global economy is estimated to have contracted by 4.3% in 2020 as a result of the pandemic.[5] More importantly, the 150 million individuals infected and over 3 million dead across 223 countries and territories clearly illustrates the WHO’s failure to contain the coronavirus. Therefore, it is less interesting to argue if the Organization failed than it is to determine how the Organization failed.
Section two begins by outlining the WHO’s response to COVID-19 and what emergency measures were implemented. Section three explores how the organization responsible for containing pandemics failed to do so and ultimately argues that the WHO was designed to fail. The WHO followed its own rules and did not deviate from their detailed pandemic emergency protocol. Three design features of the WHO produced the failure: the cost of designating a public health emergency of international concern (PHEIC); the Organization’s federal structure; and the prioritization of states’ capacity to cooperate rather than addressing states’ willingness to cooperate ultimately resulted in a chain of events similar to the 2002-2003 SARS outbreak, albeit with graver consequences. Poor organizational structure and misguided emergency preparation is entirely the fault of the WHO’s decision-making and if done differently could have lessened the harm caused by COVID-19. However, section four argues all International Organizations are inherently constrained by sovereignty and bureaucratic limitations. These findings suggest that while the World Health Organization failed to successfully prevent the COVID-19 pandemic, no International Organization would have been successful. In other words, the current model of inter-state global governance is unable to respond successfully to global challenges. This consequently opens the door to debate the purpose of International Organizations (IOs) in times of global crises. Does the value of IOs stem from their ambition to build a better future or from their realistic capacity to fix problems on the ground? This paper briefly outlines this deliberation in section five.
II: The WHO’s COVID-19 Response
While the origins of COIVD-19 are still under investigation and may date back to November 2019,[6] the World Health Organization first became aware of a ‘viral pneumonia’ on December 31st 2019 through a media statement by the Wuhan Municipal Health Commission. Following protocol, the WHO Country Office in China notified the International Health Regulation (IHR) focal point in the WHO Western Pacific Regional Office.[7] The IHR mandates governments to report public health events and provides specific criteria to determine if an event constitutes a “public health emergency of international concern.”[8] On January 1st 2020, the WHO contacted Chinese authorities, placing the first request for additional information on atypical pneumonia cases. Despite limited data, the WHO abided by the emergency response framework to better coordinate Headquarters, Regional and Country-level offices.[9] On January 2nd, the WHO repeated its request to China for information and offered the National Health Commission of the People’s Republic of China support. The WHO also informed the Global Outbreak Alert and Response Network about the viral pneumonia in Wuhan, effectively alerting public health agencies, laboratories, relevant UN agencies, International Organizations, and Non-Government Organizations around the world.[10]
By January 9th, Chinese authorities identified the pneumonia outbreak as a novel coronavirus[11] and the WHO coordinated the first teleconference with global expert networks.[12] The following day, the Global Coordination Mechanisms for Research and Development to prevent and respond to epidemics,[13] the Scientific Advisory Group of the research and development Blueprint,[14] and the Strategic and technical Advisory Group on Infectious Hazards[15] held teleconferences to coordinate expeditated research and mitigation efforts.[16] The WHO Director-General also began direct coordination with the Head of China’s National Health Commission and the Director of the Chinese Center for Disease Control and Prevention.[17] On January 11th Chinese media confirmed the first COVID-19 death.
Between January 10th and 12th, the WHO published comprehensive information packages, preparing countries to manage a potential coronavirus outbreak. Topics included infection prevention and control; laboratory testing; a national capacities review tool; risk communication and community engagement; Disease Commodity Packages, which are a series of disease specific datasheets and technical specifications; travel advice; clinical management; and surveillance case definitions. The WHO has continued to publicly provide COVID-19 specific technical information to states and the public as it becomes available, ranging from documents on clinical care and essential resource planning, to guidance for schools, workplaces and institutions, as well information for specific contexts such as humanitarian operations and refugee camps.[18]
By January 13th, this information became essential as the Ministry of Public Health in Thailand reported the first confirmed case of COVID-19 outside of China.[19] Despite the spread of the novel coronavirus over the next few weeks, it was not until January 30th that the Director-General declared the novel coronavirus outbreak a public health emergency of international concern (PHEIC).[20] By the time the WHO invoked a PHEIC, 98 cases of COVID-19 had been confirmed in 19 countries. Eight of these cases stemmed from human-to-human transmission outside of China signaling the highly contagious nature of the virus and the potential for a global pandemic.
Over the next month the WHO finalized a Strategic Preparedness and Response Plan[21] (Feb 3rd); coordinated with the UN Secretary-General to activate the UN crisis management policy (Feb 4th); urged member-states to take preemptive action[22] (Feb 4th); held daily media briefings; convened a Global Research and Innovation Forum attended by more than 450 experts and funders from 48 countries (Feb 11th – 12th); enlisted the help of 30 Silicon Valley companies to amplify safety information (Feb 13th); finalized guidelines for mass gatherings (Feb 14th)[23]; appointed six ambassadors on COVID-19 in different parts of the world to provide relevant strategic advice[24] (Feb 21st); reported findings from a WHO-China Joint Mission[25] (Feb 24th); administered advice for the use of personal protective equipment to facilitate equitable distribution[26] (Feb 27th); and published considerations for the quarantine of individuals[27] (Feb 29th).
The WHO continued to take action over the next several months, coordinating the scientific community, International Organizations, member states, and industry to ensure a united response.[28] Further, the WHO would coordinate a US$ 107.6M COVID-19 Solidarity Fund.[29] The Organization continues to be involved through international clinical trials,[30] leading communication campaigns for the general public,[31] fostering vaccine development,[32] and prioritizing care for the “poor and most vulnerable.”[33]
The actions of the WHO where clearly extensive and followed a pre-conceived action plan intended to control pandemics. A designated chain of command was followed and international experts were called on and given the necessary resources to collaborate and produce findings using the $380.4M budgeted for the prevention of epidemics and pandemics.[34] Potentially most influential, the WHO ensured information was widely distributed and amplified. Despite this herculean effort and the Organization’s overall emergency preparedness, the virus continues to spread uncontained around the world killing millions. I argue the WHO’s failure to prevent a pandemic logically stems from organizational design.
III: Designed to Fail
A Limited Toolbox: Designating a PHEIC
In instances of a potential public health emergency of international concern (PHEIC), the event is identified and reported under the International Health Regulation (IHR) and the International Health Regulations and Emergency Committees (henceforth “the Committee,”) advise the Director-General. The Director-General makes the final decision in calling a health event a PHEIC after coordinating with the Committee, scientific experts, and non-governmental sources of information to ensure impartiality. While there are several potential bottlenecks for reporting a pending pandemic under this framework, this process is deemed necessary given the severity of economic and political consequences that stem from designating a PHEIC.
PHEIC’s are binary – an event either reaches the level of risk to be considered a PHEIC, or not; there is no intermediate warning level. Therefore, the Committee is responsible for keeping the global community safe from disease outbreaks, while also attempting to do no harm. Although the WHO recognized in 2019 that a “severe influenza pandemic could cost the global economy between 1% and 5% of GDP through effects on productivity, trade and travel,” designating a PHEIC is not cost-free and also has large economic implications through restricting international trade and travel.[35] Further, the designation of a PHEIC has the potential to cost the WHO political capital. Declaring a PHEIC unnecessarily may cost the WHO legitimacy, impacting future donors and partnerships. Additionally, a PHEIC signals that a government has failed to contain a specific health threat, subsequently placing the international community at risk. While a leader’s ego may seem like a small price to pay for the health and safety of the international community, it is essential the WHO and affiliated international scientists have access to ground zero. Declaring a PHEIC may complicate cooperation. In sum, the benefits of a PHEIC must clearly outweigh the costs.
On January 20th the WHO Director-General convened an IHR Emergency Committee specifically tasked with assessing the risk of the novel coronavirus. The Committee included 15 independent experts from different regions and was tasked with determining if the COVID-19 outbreak, which had already spread within Asia and to the United States, should be classified as a PHEIC. The Committee was unable to come to an agreement[36] but provided guidance to the WHO, China, and the global community and agreed to reconvene in 10 days to reassess the situation.[37] This decision (or lack thereof) is undoubtedly frustrating given the clarity of hindsight and the prolonged harm caused by the COVID-19 pandemic. However, it is important to note the context of the Committee’s decision-making on January 23rd, defined by limited scientific knowledge about the virus, rate of infection, or COVID-19’s potential economic toll.
In an attempt to mitigate the political cost of a PHEIC declaration on January 30th, Dr. Tedros Adhanom Ghebreyesus, the WHO’s Director-General, repeatedly praised China’s initial response to the outbreak. The Director-General stated that “the Chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak” and that China’s detection, isolation, and sequencing of the virus genome was “very impressive, and beyond words.”[38] The Director-General went on to compliment China, claiming the country set “a new standard for outbreak response” and reiterated that the PHEIC declaration was “not a vote of no confidence in China. On the contrary, WHO continues to have confidence in China’s capacity to control the outbreak.”[39]
Despite this public praise, the WHO struggled to extract necessary information from China, particularly in regards to virus origins and biological material.[40] Given this situation, the WHO’s praise of China can be seen as strategic rather than purely genuine. A strong working relationship between Chinese and WHO officials was necessary to counter the spread of COVID-19. A rebuke of China’s response or resistance to sharing information with the Organization would unlikely advance the WHO’s ability to work with China. Rather, condemnation from the Organization could result in China’s continued withholding of necessary data and impede a global response. However, this unflinching support of the Health Commission of the People’s Republic of China unsettled much of the West, potentially sacrificing global cooperation as a result.
In sum, the economic and political costs of declaring a PHEIC likely contributed to the Committee’s conservative approach and delayed declaration. Beyond the economic implications, the eventual declaration of a PHEIC likely impacted the Organization’s working relationships with state governments: offending China by declaring a PHEIC and offending the West by praising China. Consequently, the WHO may benefit from an intermediate designation or veering away from a binary approach to PHEIC’s. An intermediate warning system could address future pandemics in a shorter time by minimizing associated costs. Although this suggestion is popular with policy pundits,[41] it is unlikely that an earlier designation of a PHEIC would have altered the outcome of COVID-19 given the Organization’s federal structure.
Limits of a Federal Structure
The World Health Organization is comprised of three levels of governance: Headquarters, located in Geneva Switzerland; six Regional Offices representing Africa, the Americas, South-East Asia, Europe, Eastern Mediterranean, and Western Pacific; and 150 local offices in countries, territories, and areas around the world. A federal structure is not uncommon for International Organizations, however the level of autonomy enjoyed by WHO’s Regional Offices is noteworthy.[42] Rather than being appointed by the Director-General, regional directors are nominated by the regional states and formally appointed by the Executive Board.[43] This gives regional leadership relative independence from Headquarters. Further, regional member state forums parallel the power of the World Health Assembly to set agendas and direct policy. Therefore, while Headquarters dictates policy, the true implementation of programs relies on the consent and collaboration of the six Regional Offices.[44] This structure has been critiqued, claiming the federal approach results in organizational fractionalization, increased bureaucracy, and decreased field-level effectiveness.[45] Despite these costs, the federal structure was designed with certain benefits in mind.
The need for health policy is universal since health impacts all individuals and all countries face health risks. However, what constitutes a risk differs drastically between regions. It makes sense that only Regional Offices at certain latitudes need to understand the intricacies of the WHO’s tropical disease programs. Similarly, health issues stemming from clean water scarcity require different solutions than health issues resulting from sedentary lifestyles. Regional Offices cater to these differences and offer the World Health Organization the ability to create and implement effective policy that has real impacts at the country-level. While regional independence serves relevant program implementation, it results in consequential bottlenecks in the event of emergency outbreaks or pandemics.
Despite the litany of WHO reports in early January and warnings administered by the WHO Country Office in China, it took until January 16th for the Pan American Health Organization, alternatively known as the WHO Regional office for the Americas, to issue its first epidemiological alert.[46] Similarly, the European Regional Office did not address the public until January 25th, while the South-East Asia Region waited until the 27th, the Mediterranean Region waited until their first case in the UAE to make an announcement on January 29th, and Africa waited until the 31st. This delay can largely be attributed to the regional offices’ independence and their localized perception of risk.
One of the greatest benefits of the World Health Organization is its ability to coordinate information from all over the world and share it on an equally large platform. However, few individuals outside of the public health industry listen to announcements from the WHO’s Headquarters. One of the benefits of the WHO’s regional offices and federal structure is the ability to communicate information from Headquarters in a way that resonates with Country Offices, who can then share it with local populations. However, the autonomy of regional offices allows them to communicate vital information, like the initial coronavirus alert, in their own time. Although an earlier declaration of a PHEIC by the Director-General would have likely incentivized Regional Offices to share information with their respective publics at an earlier date, it is surprising that such a drastic step is necessary for Regional Offices to engage given the coronavirus’ rate of spread. Lastly, just as Regional Offices have the autonomy to share information from Headquarters in their own time, they also have the ability to disregard or promote WHO guidance issued by Headquarters. An emergency framework that reigns in the freedom of Regional Offices could expedite responses and limit harm caused by future pandemics. This is particularly relevant given that member states are under no obligation to adhere to Organizational guidance.
Prioritizing Capacity Over Willingness
In 2003, China was slow to involve or notify the WHO of the SARS outbreak, severely limiting the speed at which the Organization could mitigate the pandemic. [47] While the reluctance of China to disclose a potential health threat was criticized, it was also rational. Governments have an understandable desire to avoid worrying citizens, deterring investors, or hindering economic trade as a result of announcing a potential health concern. However, logically, the WHO is only capable of responding to events that they are aware of and is therefore dependent on reliable reporting. To counter governmental incentive to withhold information and enable the Organization to prevent, detect, and respond to epidemics and pandemics, the WHO adapted the International Health Regulation (IHR) framework in 2005. The IHR legally requires all member states to report public health events and provides specific criteria to determine if an event constitutes a public health emergency of international concern.[48] However, state parties are responsible for the implementation of the IHR, resulting in some labeling the framework as “toothless.”[49] Despite lessons learned in 2003 and a clear legally binding emergency action plan in place, the reluctance of China to immediately report cases of “viral pneumonia” in Wuhan in late 2019 emphasizes the importance of states’ voluntary cooperation.
The WHO was first informed of the novel coronavirus on December 31st 2019. However, the virus had been circulating Wuhan for several weeks prior.[50] Delayed contact with the WHO may be a result of local Wuhan officials’ unwillingness to disclose information to Beijing, rather than intent to conceal information specifically from the Organization. News reporting indicates that local police attempted to silence Wuhan doctors from publicly speaking about the SARS-like disease.[51] However, once informed, Beijing continued to downplay the severity of the virus, failing to immediately inform the WHO of human-to-human transmission.[52] Further, it was the Chinese members of the IHR’s Emergency Committee that recommended against declaring the outbreak a PHEIC, despite Wuhan entering into a lockdown.[53] This contradiction supports theories of an ongoing battle between Chinese scientists and officials for transparency during the early weeks of the outbreak. Chinese scientists allegedly identified the coronavirus and mapped the SARS-CoV-2 genome weeks before Beijing acknowledged the potential harm caused by COVID-19.[54] Once the WHO was notified of the virus on Dec. 31st 2019, the National Health Commission of the People’s Republic of China allegedly told commercial labs to “destroy or hand over samples with the virus” and “ordered that research findings be published only after official approval.”[55] Although China’s lockdowns and strong-arm approaches were praised by the international community, it is projected that China could have reduced the total number of initial cases by 66% had officials acted a week earlier, or by 95% had they addressed the virus three weeks prior.[56]
While the IHR attempts to prevent this exact scenario by mandating countries to report health risks despite economic ramifications, there are few consequences for a member state failing to report observations. Ironically, the WHO identified “addressing health emergencies” as a key priority in the 2020-2021 programme budget, published in May 2019.[57] However, the organizational focus was overwhelmingly geared towards increasing reporting and response capacity of states with limited health infrastructure rather than strengthening legal obligations or requirements for states to report. In other words, rather than focusing on ensuring states report findings, the WHO focused on ensuring all states had the ability to report findings in the first place.
The WHO budgeted US$ 231.1M for country capacity preparedness, US$ 380.4M for the prevention of epidemics and pandemic, and US$ 277.3M for the rapid detection and response to emergencies.[58] This funding was dedicated to helping states cultivate public health systems that could withstand the initial impact of emergencies and developing normative guidance tools and toolkits to ensure all member states had the ability to abide by the International Health Regulations. Broadly speaking, this prioritization makes sense since the WHO is primarily intended to serve traditionally vulnerable populations by reinforcing health services and systems in fragile areas impacted by conflict or other vulnerabilities.[59] The WHO does this well, mitigating over 100 epidemic-prone events each year.[60] The failure of the Organization’s response to COVID-19 is not based on its ability to reinforce struggling health systems but rather its failure to buttress the legal requirements of states with strong health infrastructure and high monitoring capacities. Despite the 888.8M budgeted for health emergency protection, there was no effort to advance WHO’s legal framework or give the IHR teeth.
The Organization’s focus on capacity rather than willingness also applies to the implementation of policy. As exemplified by the budget and programme goals above, the WHO prioritized increasing state capacity to respond to outbreaks rather than enforcing the legal requirement to implement WHO policy in the event of a PHEIC. It is up to member states to determine if they agree with the WHO’s declaration of a PHEIC. WHO guidance remains accessible, regardless of state rhetoric, in the hope that states eventually implement policy that avoids unnecessary spread and travel interference.[61]
Therefore, despite a PHEIC, states varied in terms of timing and the comprehensiveness of their response to COVID-19. States’ disregard of WHO policy is evident by President Trump’s refusal to unequivocally support, let alone mandate, facemasks[62] or Sweden’s reluctance to require social distancing.[63] While the deviation of policy implementation hypothetically aligns with different country specific scenarios and allows for states to make fitting decisions based on risk, the WHO’s capacity to prevent the spread of pandemics is ultimately hindered by an organizational focus on providing guidance rather than mandating states to enforce public health guidance. This was particularly relevant during the COVID-19 pandemic given that the WHO’s response to the novel coronavirus was faster than past responses to MERS or SARS.[64] Unfortunately, member states did not match the international response.
To be clear, the WHO’s focus on enhancing state capacity and prioritizing funding for nations without strong health infrastructure was not a mistake. However, the Organization’s failure to recognize and address issues stemming from state willingness likely contributed to the persistence and severity of the COVID-19 pandemic. Overall, the alert system for emergencies (PHEIC), autonomous federal structure, and deprioritization of state willingness help explain the Organization’s failure to contain the COVID-19 outbreak. In as far as these factors clarify the WHO’s failure to contain the COVID-19 pandemic, blame rests entirely with the Organization; these factors are under the control of WHO decision-making, and are therefore subject to change. Alternatively, states’ unwillingness to abide by WHO requirements or refusal to implement policy may simply be an unavoidable feature of International Organizations operating in an international system of sovereign states.
IV: The Limits of International Organizations
This paper argues that the WHO failed because it did not prevent the pandemic (as indicated by the Organizational mandate). However, this argument can be countered by a different conceptualization of failure, primarily that failure of an organization is contingent upon its capacity. It would be unfair to critique an organization on an outcome that falls outside of the realm of possibility. For example, it is unreasonable to expect the World Health Organization to prevent all disease when illness is a natural part of life, particularly given global travel, urbanization, and climate change. Similarly, it would be wrong to critique the Organization for state policy that contradicts WHO advise, as this is beyond scope of the Organization’s reach. International Organizations are fundamentally limited by a global system that prioritizes state sovereignty and the importance of economic growth. Therefore, contextualizing the World Health Organization’s failure to contain the COVID-19 pandemic requires analyzing the actions of the Organization in accordance with its limitations.
The Limitations of Sovereignty
International Organizations (IO) are not independent entities from their member states, but rather are comprised of member states. While this may seem obvious, it is necessary to recognize that IOs do not have the ability to act independently from member states. In other words, the World Health Organization is unable to override state sovereignty. This means the Organization cannot force states to: implement policy; allow the WHO unfettered access to state-specific information; or provide the WHO with funds. Therefore, even if the Organization had prioritized state willingness by giving the IHR teeth or increasing the legal obligation of states to report to and abide by the WHO, the consequences for member states defecting on IO agreements or treaties is limited. As a result, IOs generally resort to naming and shaming or restricting state participation within IO councils to pressure state compliance. However, these tactics are less influential during a crisis where the international community only becomes aware of a state’s failure to report a viral outbreak once it’s too late. Although IOs inability to force state compliance complicates emergency response (particularly when dealing with a virus transmitted by human-to-human contact in a globalized world), this limitation is for good reason since no one votes for the WHO’s Executive Board. This limitation is not specific to the World Health Organization but rightly constrains all IOs. Consequently, the WHO’s commitment to preventing pandemics may have been overly ambitus.
Overall, IOs ability to respond to global crises is largely dependent on the good faith of member states. Specifically, the WHO’s ability to respond to health emergencies is conditional on information shared by member states and the capacity and willingness of member states to implement WHO recommendations such as travel and trade closures, issue early warnings, or pre-deploying staff and equipment. In other words, while the WHO has the power to ring the alarm, share information, and contribute to mitigating the spread of infection by supporting health infrastructure, the effectiveness of this system is determined by the cooperation of sovereign member states.
The Limitations of Economic Growth
Like most International Organizations, the WHO requires assessed contributions – payments by states legally mandated in exchange for membership to the Organization. Assessed contributions are determined by a country’s wealth and population, ranging from US$ 10,770 for small and developing nations like Vanuatu to US$ 236,911,350 paid by the United States.[65] However, unlike most International Organizations, assessed contributions comprise little more than 14% of the WHO’s projected 2020-2021 budget.[66] The vast majority of funding comes from voluntary contributions, recently comprising more than 80% of the Organization’s total budget.[67] This means the WHO’s capacity to procure and distribute vaccines, provide prenatal care, coordinate and promote scientific research, or respond to a global pandemic is almost entirely dependent on the willingness of donors to contribute funding. This dependence on good-faith donors is compounded by the WHO’s reliance on non-state donors.
Unlike assessed contributions, voluntary contributions are not restricted to member states and can be sourced from other public and private partners. The Bill and Melinda Gates Foundation is the WHO’s second largest donor, equivalent to 11.65% of the Organization’s total budget.[68] Non-state actors supplied almost half of WHO’s revenue during the 2016-2017 biennium[69] and this percentage appears to be consistently growing.[70] While contributions from non-state actors currently ensure the functionality of the WHO, their voluntary involvement has raised concerns about the WHO’s financial stability.
That said, all IOs face funding uncertainty. International Organizations dependent on assessed contributions may have legal recourse when states delay or defect on their payments, but this does not guarantee payment. Economic downturns that limit a donors’ capacity impacts both voluntary and assessed contributions. WHO member states have consistently failed to contribute their required assessed contributions.[71] For example, the US owed more than US$ 200M in assessed contributions for 2020 and 2019 before President Trump formally withdrew from the Organization in July 2020.[72] Regardless of funding structure, IOs are always limited by unreliable financial constraints.
Beyond legal recourse for failed payments, critics additionally argue voluntary contributions make the WHO more beholden to large donors, pressuring the Organization to make recommendations or implement policy that is politically advantageous for high-contributing states. While this issue is of particular concern for an organization striving for impartiality, assessed contributions do not alleviate this struggle; high contributing donors would continue to have leverage to promote their policy of choice. Therefore, the political independence of all IOs is somewhat constrained regardless of funding structure.
Lastly, economic downturns impact an organization’s ability to attract funding, limiting the ability to implement programs or serve populations. While economic downturns effect all organizations, governments, and individuals, it is necessary to recognize IOs have the capacity to cause economic downturns. For example, a premature declaration of a PHEIC by the WHO, or an advisory to close borders or restrict international trade or travel has severe economic implications. Consequently, in an attempt to stabilize funding, the WHO has incentive to wait until more information comes to light before declaring a PHEIC, or to downplay a potential threat. This is because while the WHO is tasked with advancing health for all, the Organization is also rooted in the global economy. It is impossible for IOs to be completely impartial when the capacity for future capital is also implicated by their decision-making. This is a limitation of all IOs since organizations cannot be extracted from a capitalist world system. While the economic burden of IOs is not inherently negative since organizations should be cognizant of the full implications of their actions and policy recommendations, it is necessary to acknowledge that, just like states, there is an incentive for conservative IO policy.
V: So What: A Look at the Broader Picture
A layperson’s definition of the World Health Organization’s success is likely tied to the Organization’s ability to prevent or contain the COVID-19 pandemic. Using this benchmark, the WHO failed as the coronavirus continues to spread globally. The WHO’s organizational definition of success can be linked to their mandate and General Programme of Work, indicating a commitment to preventing epidemics and pandemics. Using this definition, the WHO failed as the COVID-19 death count continues to climb. However, understanding success in terms of following organizational protocol, committing no harm, and acting as an overall positive force offers a different lens of analysis. The net outcome of the WHO’s COVID-19 efforts remains to be determined since, at the time of writing, the pandemic appears to be far from over. However, it seems unlikely that another organization could have united the international scientific community, amplified public health messaging, and coordinated the distribution of supplies at the speed and to the extent the WHO did. Even if the World Health Organization’s overall response to the COVID-19 pandemic is a failure, the Organization’s efforts ultimately aided the world in a time of crisis. However, the contradiction between falling short of the overall objective and still contributing positively to survival efforts points to an important question: what is the purpose of International Organizations?
Should IOs commit themselves to overly-ambitious goals like preventing pandemics? Or should IOs limit their focus on providing realistic assistance to on the ground problems? Ambition is largely seen as a prerequisite for great achievements. Addressing complex and systematic problems requires industrious, determined, and potentially improbable solutions. The lofty goals of International Organizations, like solving climate change, preventing pandemics, or ending poverty pave the way for a better future. IO’s commitment to untenable goals force actors to think big and potentially accomplish more than previously deemed possible, enacting the old adage found on elementary school classroom walls: “Shoot for the moon. Even if you miss, you’ll land among the stars.”[73] Conversely, consistently falling short of goals risks decreasing an organization’s legitimacy. For example, a commitment to reversing climate change may be seen as so improbable that states’ refuse to take negotiations seriously or buy into IO efforts. Similarly, the WHO’s commitment to prevent pandemics may be perceived as so outlandish that state and non-state actors limit their financial contributions. Potentially an IO can accomplish more by setting and completing realistic goals that benefit pre-designated communities. I argue that this debate is irrelevant.
Determining the benefits of aspiration vs practicality is a false dichotomy. Being ambitious and realistic are not mutually exclusive. As the WHO’s response to COVID-19 illustrates, an IO can be overly ambitious (aiming to prevent pandemics) and provide realistic help for those in need in times of crisis (distribute supplies, assist in vaccine development, etc.). While it is possible that an overly ambitious goal may result in unparalleled benefits, it will most likely end in failure. Falling short of a stated output and the subsequent perception of failure is the only risk the WHO took by committing to the grandiose vision of preventing pandemics. This is because the Organization is structured to allow donor contributions to specific programmes, buffering the Organization’s legitimacy and ensuring buy-in based on the feasibility of projects. Therefore, failing to prevent or confine the COVID-19 pandemic did not impact the WHO’s capacity to do good. In other words, the WHO failed and simultaneously, the world would have been worse off without their efforts. While limited implications of failure may not be true of all IOs, the irrelevant failure of the WHO explains my hesitancy to provide policy recommendations.
VI: Conclusion
The Organization’s ability to prevent the COVID-19 pandemic was ultimately hindered by 1) the costly designation of a PHEIC, 2) the unnecessary bottlenecks created by a federal structure, and 3) the WHO’s failure to prioritize the willing cooperation of states. Although these issues can be addressed, this paper does not provide policy proposals. Given the Organization’s mission to “promote health, keep the world safe and serve the vulnerable,”[74] issues stemming from state capacity are far more likely than issues resulting from state willingness. Although enforcing willingness may have led China to report infection to the WHO weeks earlier and may have forced reluctant state governments to abide by WHO public health advisories, enforcing state cooperation is unlikely given the constraints of the international system. Limitations of sovereignty and required economic growth undoubtedly contributed to the WHO’s failure to prevent COVID-19. However, these factors restrict all International Organizations, reducing the extent to which the WHO can be critiqued.
Overall, the WHO ultimately did not meet the expectations of laypeople nor did the Organization achieve its own definition of success. The WHO failed. And yet, the WHO responded to the COVID-19 pandemic relatively quickly and efficiently and likely mitigated even worse outcomes. The Organization alerted states early, made difficult decisions under imperfect information, provided states with up-to-date scientific guidance for specific scenarios and settings, and attempted to support the world’s most vulnerable. Ultimately, the WHO provided tangible benefits to communities around the world, proving that the success of an IO’s mission does not equate with overall value.
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[33] World Health Assembly, “73 World Health Assembly,” May 19, 2020, https://apps.who.int/gb/Journal/e/WHA73/JRN-A73-2_en.html.See also World Health Organization, “Global Partnership to Make Available 120 Million Affordable, Quality COVID-19 Rapid Tests for Low- and Middle-Income Countries,” September 28, 2020, https://www.who.int/news/item/28-09-2020-global-partnership-to-make-available-120-million-affordable-quality-covid-19-rapid-tests-for-low--and-middle-income-countries.
[34] World Health Organization, “Programme Budget 2020-2021.”
[35] World Health Organization, “Programme Budget 2020-2021.” 50
[36] World Health Organization Director-General, “WHO Director-General’s Statement on IHR Emergency Committee on Novel Coronavirus,” February 22, 2020, https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus.
[37] World Health Organization Director-General, “WHO Director-General’s Statement on the Advice of the IHR Emergency Committee on Novel Coronavirus,” January 23, 2020, https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-the-advice-of-the-ihr-emergency-committee-on-novel-coronavirus.
[38] World Health Organization Director-General, “IHR Emergency Committee on Novel Coronavirus (2019-NCoV),” January 30, 2020, https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov).
[39] ibid
[40] World Health Organization, “WHO, China Leaders Discuss next Steps in Battle against Coronavirus Outbreak.”
[41] World Health Organization, “Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme, A73/10, Agenda 13.1,” November 4, 2020, https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_10-en.pdf.
[42]Yves Beigbeder, The Internal Management of United Nations Organizations: The Long Quest for Reform (Springer, 2016).
[43] WHO Constitution, art 52
[44] Robert Warburton Cox and Harold Karan Jacobson, The Anatomy of Influence. Decision Making in International Organization. By Robert W. Cox and Harold K. Jacobson [and Others]. (Second Printing.). (New Haven & London: Yale University Press, 1974).
[45] Erin R. Graham, “International Organizations as Collective Agents: Fragmentation and the Limits of Principal Control at the World Health Organization,” European Journal of International Relations 20, no. 2 (June 1, 2014): 366–90, https://doi.org/10.1177/1354066113476116. See also Ruth Levine, “Open Letter to the Incoming Director General of the World Health Organization: Time to Refocus,” BMJ : British Medical Journal 333, no. 7576 (November 11, 2006): 1015–17, https://doi.org/10.1136/bmj.39020.383102.68.
[46] Pan American Health Organization, “Epidemiological Alert Novel Coronavirus (NCoV),” January 16, 2020, https://www.paho.org/hq/index.php?option=com_docman&view=download&category_slug=coronavirus-epidemiological-alerts-and-updates&alias=51348-16-january-2020-novel-coronavirus-ncov-epidemiological-alert&Itemid=270&lang=en.
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[48] World Health Organization, “International Health Regulations.”
[49] Oona Hathaway and Alasdair Phillips-Robins, “COVID-19 and International Law Series: Reforming the World Health Organization,” Just Security, December 11, 2020, https://www.justsecurity.org/73793/covid-19-and-international-law-series-reforming-the-world-health-organization/.
[50] ibid
[51] ibid
[52] Bill Bostock, “China Knew the Coronavirus Could Become a Pandemic in Mid-January but for 6 Days Claimed Publicly That There Was No Evidence It Could Spread among Humans,” Business Insider, accessed January 11, 2021, https://www.businessinsider.com/coronavirus-china-hid-pandemic-news-six-days-2020-4.
[53] World Health Organization, “Statement on the Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus 2019 (n-CoV) on 23 January 2020,” January 23, 2020, https://www.who.int/news/item/23-01-2020-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov).
[54] Chris Buckley et al., “25 Days That Changed the World: How Covid-19 Slipped China’s Grasp,” The New York Times, December 30, 2020, sec. World, https://www.nytimes.com/2020/12/30/world/asia/china-coronavirus.html.
[55] ibid
[56] Shengjie Lai et al., “Effect of Non-Pharmaceutical Interventions to Contain COVID-19 in China,” Nature 585, no. 7825 (September 2020): 410–13, https://doi.org/10.1038/s41586-020-2293-x. See also “25 Days That Changed the World.”
[57] World Health Organization, “Programme Budget 2020-2021,” May 2019, https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_4-en.pdf.
[58] ibid
[59] ibid
[60] ibid, 50
[61] World Health Organization, “Ten Things You Need to Do to Implement the International Health Regulations,” May 26, 2014, https://www.who.int/news-room/q-a-detail/ten-things-you-need-to-do-to-implement-the-international-health-regulations.
[62] Daniel Victor, Lew Serviss, and Azi Paybarah, “In His Own Words, Trump on the Coronavirus and Masks,” The New York Times, October 2, 2020, sec. U.S., https://www.nytimes.com/2020/10/02/us/politics/donald-trump-masks.html.
[63] Thomas Erdbrink and Christina Anderson, “‘Life Has to Go On’: How Sweden Has Faced the Virus Without a Lockdown,” The New York Times, April 28, 2020, sec. World, https://www.nytimes.com/2020/04/28/world/europe/sweden-coronavirus-herd-immunity.html.
[64] Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme, “Interim Report on WHO’s Response to COVID-19 January-April 2020” (WHO, April 29, 2020), https://www.who.int/publications/m/item/interim-report-on-who-s-response-to-covid---january---april-2020.
[65] World Health Organization, “Programme Budget Web Portal: Contributors Overview,” Q3 2020, http://open.who.int/2020-21/contributors/overview/ac.
[66] World Health Organization, “Programme Budget Web Portal: By Contributor,” Q3 2020, http://open.who.int/2020-21/contributors/contributor.
[67] Daugirdas and Burci, “Financing the World Health Organization.”
[68] World Health Organization, “Programme Budget Web Portal: Bill & Melinda Gates Foundation,” Q3 2020, http://open.who.int/2020-21/contributors/contributor?name=Bill%20%26%20Melinda%20Gates%20Foundation.
[69] See World Health Organization, “WHO Results Report: Programme Budget 2016–2017, 71st World Health Assembly, Agenda Item 15.1,” May 2018, https://www.who.int/about/finances-accountability/budget-portal/rr_2016-17.pdf.
[70] Daugirdas and Burci, “Financing the World Health Organization.”
[71] See Yves Beigbeder et al., The World Health Organization, International Organization and the Evolution of World Society, v. 4 (The Hague ; Boston: M. Nijhoff, 1998). See also Daugirdas and Burci, “Financing the World Health Organization.”
[72]Gaulkin, “Pandemic Failure or Convenient Scapegoat: How Did WHO Get Here?”.
[73] Quote attributed to Norman Vincent Peale (1898-1993)
[74] World Health Organization, “Our Values,” accessed January 11, 2021, https://www.who.int/about/who-we-are/our-values.