An Assessment Panel assessing the response of the World Health Organization (WHO) to the Ebola crisis concluded, in no uncertain terms, that, “The Ebola crisis . . . exposed organizational failings in the functioning of the WHO,” and called for important organizational reforms. While insightful, the analysis looks at the current situation with little attention to the historical context leading to existing deficiencies. Without understanding the sources of the current problems, it might be hard to fix them.
The WHO’s organizational difficulties today are not inherent or necessary aspects of this or any other international organization. Indeed, during most of its existence, the WHO was one of the more respected UN agencies. Instead, the WHO was thwarted by policy changes implemented over the past twenty years, which have undermined its operational capabilities and neglected poor countries’ health care infrastructure. The consequences of those changes today—lack of international alertness and a dire situation of health clinics in many countries—is why Ebola has turned into an international emergency, which could and should have been prevented.
Many of these changes at the WHO were made in response to forces beyond the organization’s control. Consider the issue of insufficient funds, for example. In addition to budget cuts demanded by member-states, the WHO was forced to increasingly rely on voluntary rather than mandatory contributions. These voluntary contributions are usually “earmarked” for specific causes, so that the WHO—and most of its member-states—have little say in how the money is spent and no ability to reallocate the funds as urgent needs arise. In turn, a limited budget and pressures to rely on cost-effective calculations have driven the WHO to increase its focus on non-communicable diseases (such as diabetes), often at the expense of communicable diseases. Where the WHO and other international organizations do continue to concentrate on communicable diseases, the available funds have been concentrated on AIDS, tuberculosis, and malaria, and while there have been impressive gains in fighting these disease, often the programs bypass the existing local health systems and thereby weaken them.
Radical fragmentation in the international health world has also contributed to the neglect of local health systems. The WHO, which used to be the sole authority over international health issues, is now one actor amongst many, including large organizations like the Global Fund to Fight AIDS, Tuberculosis and Malaria, and many smaller public-private partnerships, such as the GAVI Alliance. These smaller partnerships are often funded by private foundations, first and foremost the Bill and Melinda Gates Foundation. Such fragmentation—where different organizations have responsibility over diverse specific goals—offers many advantages. The GAVI Alliance, for example, has been fundamental in improving access to vaccines, and would no doubt be a key player if and when a vaccine to Ebola is developed. But such organizational cacophony is particularly ill-equipped to support the kind of local health systems that have been so tragically missing in the current Ebola crisis, and is ill-equipped to do the kind of detection that the WHO has been responsible for. The Gates Foundation acknowledged as much by giving its first donation to fight the Ebola outbreak, in the amount of $5 million, to the WHO for emergency operations.
Some would argue that the incredible work done by Médecins Sans Frontières (MSF) in its response to Ebola, and in many other cases as well, suggest, on the contrary, that a fragmented, from the bottom-up, response is the most effective one. In other words, then rather than fixing the WHO, we could rely on other agencies that might be more effective. But MSF is the solution only when there are no other solutions. Private donations and heroic volunteers have been extraordinary resources in the Ebola crisis—but what we really need is a well-functioning World Health Organization that has the funds and authority to prevent the reliance on donations and volunteers in the first place. The Assessment Panel is a good start for thinking seriously about how to reform the WHO. But for an effective reform, I argue, we need the collaboration of member-states and neighboring organizations, and an understanding of their own contribution to the current fate of the WHO.
Nitsan Chorev is the Harmon Family Professor of Sociology and International Studies at Brown University’s Watson Institute for International Studies and author of The World Health Organization between North and South.