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p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 8 8e1 9 4

Available online at w

Public Health

journal homepage: www.elsevier .com/puhe

WHO: Past, Present and Future

Split WHO in two: strengthening politicaldecision-making and securing independentscientific advice

Steven J. Hoffman a,b,c,d,*, John-Arne Røttingen c,d,e,f

a Department of Clinical Epidemiology & Biostatistics and McMaster Health Forum, McMaster University,

Hamilton, Canadab Global Health Diplomacy Program, Munk School of Global Affairs, University of Toronto, Canadac Department of Global Health & Population, Harvard School of Public Health, Boston, MA, USAd Harvard Global Health Institute, Harvard University, Cambridge, MA, USAe Department of Health Management & Health Economics, Institute of Health & Society, University of Oslo, Norwayf Norwegian Institute of Public Health, Oslo, Norway

a r t i c l e i n f o

Article history:

Received 10 May 2013

Received in revised form

21 August 2013

Accepted 29 August 2013

Available online 14 January 2014

Keywords:

World Health Organization

Public health politics

Global governance

International institutional law

* Corresponding author. 1280 Main Street WeE-mail address: hoffmans@mcmaster.ca

0033-3506/$ e see front matter ª 2013 The Rhttp://dx.doi.org/10.1016/j.puhe.2013.08.021

a b s t r a c t

The World Health Organization (WHO) has never fulfilled its original mission of simulta-

neously serving as the world’s pre-eminent public health authority and intergovernmental

platform for global health negotiations. While WHO’s secretariat works hard to fulfill both

functions, it is undermined by an institutional design that mixes technical and political

mandates. This forces staff to walk uncomfortably along many fine lines: advising but

never directing; guiding but never governing; leading but never advocating; evaluating but

never judging. The result is mediocrity on both fronts. Instead, WHO should be split in two,

separating its technical and political stewardship functions into separate entities, with

collaboration in areas of overlap. The Executive Board and secretariat would be bifurcated,

with technical units reporting to a Technical Board and political units reporting to a Po-

litical Board. Both boards would report to the World Health Assembly where all member

states would continue to provide ultimate oversight. Such bold changes can be imple-

mented either by revising WHO’s constitution or through simpler mechanisms. Either way,

structural governance reforms would need to be accompanied by complementary changes

in culture that support strengthened political decision-making and scientific indepen-

dence. States’ inability to act on WHO’s institutional design challenges will only lead them

and non-state actors to continue bypassing the organization through the creation of new

entities as they have done over the last 15 years. The key will be to mobilize those advo-

cates and decision-makers who have the audacity to demand more from WHO and

convince member states to elevate their ambitions in current WHO reform efforts.

Continued progress in global health depends on it.

ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

st, MML-417, Hamilton,(S.J. Hoffman).oyal Society for Public H

Ontario L8S 4L6, Canada. Tel.: þ1 905 525 9140x22121.

ealth. Published by Elsevier Ltd. All rights reserved.

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 8 8e1 9 4 189

An organization from an earlier era

The structure, functions and bold vision of the World Health

Organization (WHO) reflect the optimistic moment of its cre-

ation. The agency’s constitution was adopted on July 22, 1946:

World War II had just ended a year earlier, and the winning

powers promised their allies an era of peace and prosperity

through a newly created United Nations (UN). Every state was

said to be equal; rapid scientific developments made every

problem seem solvable: if only the world’s peoples worked

together. Multilateral institutions were created to facilitate

harmonious international relations, and secretariats were

established to provide neutral technical support and imple-

ment member states’ collective ambitions. Health was a clear

goal around which formerly warring countries could theoret-

ically rally. Its achievement was ‘of value to all’, its enjoyment

was ‘one of the fundamental rights of every human being’,

and its neglect represented ‘a common danger.’1 Encoded into

the organization’s constitution and culture was the belief that

‘the health of all peoples is fundamental to the attainment of

peace and security and is dependent upon the fullest co-

operation of individuals and States.’1

But global solidarity proved elusive and promises of ‘fullest

co-operation’ nevermaterialized. The Iron Curtain divided the

world, turning every multilateral institution into a diplomatic

battleground for supranational influence, economic rivalry,

North-South bickering and East-West politicking. WHO was

no exception. It too was plagued by maddening intergovern-

mental machinations and nasty power politics.2 The situation

has only become more complex since the Berlin Wall crum-

bled. Instead of two sides e communism and capitalism e the

world is now multidimensionally fractured: by development

status; government capacity; social values; research needs

and industrial interests; to name a few.

Technical and political mediocrity

It is unsurprising, then, that the original vision for a single UN

entity to simultaneously be the world’s pre-eminent public

health authority and intergovernmental platform for global

health negotiations was never fully realized. Of course, much

has been accomplished in its 65-year history: WHO helped

eradicate smallpox; standardize medical nomenclature; build

a pandemic response network; and mobilize a global fight

against tobacco. But much of its technical work is unexcep-

tional. WHO recommendations do not always align with the

best available evidence,3e5 its health statistics have been

* According to WHO’s annual human resources report, 32.9% ofits employees are ‘professional and higher grade staff’; 13.7% are‘national professional officers’ and the remaining 53.4% are‘general service staff’ who provide secretarial, clerical, buildingmanagement, information technology, printing and protectivesupport. Among WHO’s professional staff, 47.8% are ‘dental,nutrition, medical, nursing and veterinary specialists’, of which91.7% are ‘medical specialists’. This means that doctors represent43.8% of WHO’s professional staff (i.e., 91.7% � 47.8%) and 14.4%of its total staff (i.e., 91.7% � 47.8% � 32.9%). The next threelargest categories of professional staff are ‘administrative spe-cialists’ (34.5%), ‘life scientists’ (3.5%) and ‘writers, translators andinterpreters’ (3.1%).6

challenged by the Gates-funded Institute for Health Metrics &

Evaluation (IHME), its strategy on research for health remains

largely unfulfilled, and its co-ordinating role is ill-defined in a

landscape of many global health financing and delivery ini-

tiatives like the GAVI Alliance and Global Fund to Fight AIDS,

Tuberculosis & Malaria. While an impressive 43.8% of WHO’s

professional staff are medical specialists, only 0.1% are

economists and only 1.4% and 1.6% are lawyers and social

scientists, respectively.6,* With some notable exceptions, the

world’s best public health minds and practitioners generally

do not stay at WHO for very long given the organization’s

hierarchical bureaucracy, limited financial resources, resis-

tance to change, avoidance of difficult issues, overabundance

of meetings, tolerance of unequal work effort among staff,

proactive deference to powerful member states, and frequent

cross-cultural misunderstandings in the workplace (particu-

larly around gender). Rather, these technical and opinion

leaders are found in academia, civil society, government and

industry, often serving on WHO’s many expert advisory

committees, issuing recommendations and reports which

may or may not be implemented. Over 50% of WHO staff

either believe or ‘don’t know’ whether the organization is

inappropriately influenced by industry, and 25% have doubts

about the independence of its expert advisors.7 Fewer than

20% of staff believe top management cares about them; 65%

are concerned about the organization’s future.8

Yet in addition to technical mediocrity, WHO has also not

fulfilled its bold promise as an effective political platform for

international health negotiations. Many global health prob-

lems remain unresolved despite decades of heated debate,

such as access to medicines, antimicrobial resistance, family

planning, health workforce migration, research for neglected

diseases, social determinants of health and substandard/

spurious/falsely-labelled/falsified/counterfeit medical prod-

ucts. The organization has not harnessed the full range of its

constitutional powers; it has crafted very few Article 21 reg-

ulations (e.g., International Health Regulations), facilitated

adoption of just one Article 19 convention (i.e., Framework

Convention on Tobacco Control), and created merely a single

Article 18 sub-agency (i.e., International Agency for Research

on Cancer). Only two WHO codes of practice have achieved

any prominence, namely those on breast-milk substitutes and

international recruitment of health personnel, and their

impact may be limited; 93% of health workforce planners

surveyed in the four English-speaking countries with themost

migrant health workers revealed the latter code prompted no

specific changes to their work.9 Rhetoric aboutWHO’s political

successes does not always withstand empirical scrutiny.

Both technical and political functions of the organization

are also undermined by the way it is financed, governed and

bypassed. First, WHO’s core budget is perennially insufficient

for the actions it is asked to perform by member states, which

means the tasks accomplished by the secretariat end up

aligning more with individual donor priorities than either the

global burden of disease10 or countries’ stated health needs.11

Indeed, WHO ranks #134 out of 151 development organiza-

tions for supporting countries inways that are salient to them,

despite health issues like malnutrition, HIV/AIDS and infant

mortality attracting some of the highest levels of donor-

recipient alignment across 34 development challenges.11

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 8 8e1 9 4190

Second, gross inequalities of influence persist among states in

global health decision-making at both the World Health As-

sembly and Executive Board. Like many UN institutions, WHO

claims superordinate normative authority based on having an

egalitarian one-state-one-vote governance model, yet this

claim is continuously undermined by the equality-influence

gap that exists between the rhetoric of parity and the reality

of international politics.12 Third, global health governance it-

self has become highly fragmented. Today there are over 26

UN entities, 40 bilateral development agencies, 20multilateral

development funds and 90 global health initiatives;13,14 pub-

liceprivate partnerships have popped up everywhere with

mixed results;15,16 and multinational companies are as so-

phisticated as ever in injecting themselves into global health

debates, asserting their interests and interfering with public

health initiatives that affect them.17,18 Some argue this

increasing multiplicity of actors has weakened the global

health system.19 Many of these initiatives were created in

direct response to perceivedWHO failures and as institutional

by-passes of WHO’s outdated and inadequate governance

arrangements.20

Confusing mandates

WHO faces a crisis of identity. Back in 1946, the world needed

institutions capable of advancing public health science and

facilitating effective global health negotiations. These needs

persist today and are as desperate as ever. WHO’s secretariat

works hard to fulfil both functions. Yet it has become clear

that the postwar experiment of combining technical and po-

litical mandates within a single multilateral institution for

health has largely failed. Today’s global political ‘adhocracy’ is

messy. Mixing these messy politics with ‘technocracy’ is

counter-productive without appropriate checks and balances.

The outcome is sullied decision-making, opaque processes,

unclear priorities, apprehension of bias, distraction from

global health needs, and doubts about quality. The lack of

technical independence reduces freedom of operation and

caps the boldness, sophistication and clarity of scientific an-

alyses and conclusions. Likewise, a secretariat mainly

recruited for its scientific and technical competencies is ill-

suited to support effective international political negotia-

tions. For that function, experts in diplomacy, global gover-

nance, international relations, political economy and strategic

communications may be more effective, albeit scarce.21

Instead, WHO staff are forced to walk uncomfortably along

many fine lines: analysing but never auditing; advising but

never directing; participating but never interfering; guiding

but never governing; leading but never advocating; evaluating

but never judging. And staff walk these lines quite well. But no

institution e no matter how well run e can be everything to

everyone at every point in time, especially under the exces-

sively limiting conditions that member states impose.

There is a reason states often divide authority in domestic

contexts, including in health, where national public health

authorities like the USA’s Centers for Disease Control & Pre-

vention (CDC), health technology assessment agencies like

the UK’s National Institute for Health & Clinical Excellence

(NICE), health regulators likeMexico’s Federal Commission for

the Protection against Sanitary Risk (COFEPRIS), research

funders like South Africa’s Medical Research Council (MRC),

and knowledge brokering institutions like the Norwegian

Knowledge Centre for the Health Services (NOKC) typically

enjoy significant autonomy from their politically-led minis-

tries. Indeed, they are often completely separate from minis-

tries of health or function as semi-protected arms-length

bodies with clear mandates, independence and legal safe-

guards from political actors. The result is better technical

work that strengthens political decision-making by providing

higher-quality independent scientific advice. Political pro-

cesses are free to be managed by politically astute staff, and

technical work can be commissioned and guided towards

areas of highest political priority.22 The case for a politically

neutral and scientifically independent public health authority

is even greater at the international level, where it is not just

one government that can interfere in technical work but

almost 200 governments.23 Likewise, these 200 governments

probably require a much higher level of political coordination

by an even more politically talented and relevantly trained

staff than might be needed to achieve progress in domestic

contexts.

Doomed by design and in desperate need of institutionaltransformation

In sum,WHO is an organization that, by design, is incapable of

achieving its potential. It has a governance structure that was

crafted for a different time and that has not served the orga-

nization since that time’s passing. Over the years matters

have only worsened, with the Executive Board, for example,

formally codifying in 1998 the accepted practice of its ‘tech-

nically qualified’ expert members actually working as ‘gov-

ernment representatives’ of the country that nominated

them.24 This board now functions as a political preparatory

body for the World Health Assembly, which itself may be a

helpful function, but which unhelpfully results in technical

issues being neglected and not properly followed through at

the highest governance level.

WHO does not need tweaks; it needs significant institu-

tional transformation. Prospects formeaningful improvement

in the near-term depend on generating enough political will to

elevate ambitions for WHO reform efforts beyond the meagre

changes currently being implemented.

An ambitious proposal: split WHO in two,separating technical and political stewardshipfunctions

Among the many potential reforms, one of the most impor-

tant is securing greater autonomy for the technical part of the

organization’s secretariat, an idea for which others have

already argued.25,26 This means a protected and adequate

budget with flexibility over how it is allocated; priority-setting

processes and guideline development informed by the best

available evidence; opportunities and clear policies for

collaboration with external partners, including robust safe-

guards against inappropriate influence or interference by

individual states, civil society organizations, philanthropies

and companies; reports, research and recommendations

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 8 8e1 9 4 191

issued free of political interference; leadership unencum-

bered by favours owed as a result of vote-buying in non-

transparent elections; and answerability not for the whims

and wishes of powerful interests, particular states or phil-

anthropic faddism, but for socially justifiable imperatives like

health impact, rule of law, morality, fairness, equity and

reasonableness. Equally important is boosting the secretar-

iat’s capacity to support political stewardship, which is about

helping states provide clear strategic directions for the orga-

nization, proper oversight for the global health system, and

advocacy for health in other policy arenas like trade, intel-

lectual property, human rights and the environment. This

means having credible and legitimate political processes that

are supported by staff who are top specialists in convening

negotiations, facilitating consensus-building, guiding rule-

making, engaging partners across regimes, and fostering

multidimensional accountability.14

Ideally WHO would be split in two, dividing the secretar-

iat’s technical functions and political stewardship functions

into separate entities, with collaboration between the two

divisions in areas of overlap (see Table 1). The Executive

Board and Director-General post would be similarly bifur-

cated; technical units would report up to a chief technical

officer, and political stewardship units would report to a chief

political officer, who in turn would each report to a Technical

Board and Political Board, respectively. The Technical Board

would be composed of individual experts serving in their

personal capacities, whereas members of the Political

Board would represent their governments or regional

Table 1 e Technical and political stewardship functions of WH

Political stewardship functions

(a) to act as the directing and co-ordinating authority on international h

(b) to establish and maintain effective collaboration with the United N

professional groups and such other organizations as may be deemed

Both political stewardship functions and technical functions

(c) to assist Governments, upon request, in strengthening health service

(k) to propose conventions, agreements and regulations, and make rec

perform such duties as may be assigned thereby to the Organization

Technical functions

(d) to furnish appropriate technical assistance and, in emergencies, nec

(e) to provide or assist in providing, upon the request of the United Nation

of trust territories;

(f) to establish andmaintain such administrative and technical services a

(g) to stimulate and advance work to eradicate epidemic, endemic and o

(h) to promote, in co-operation with other specialized agencies where n

(i) to promote, in co-operation with other specialized agencies whe

recreation, economic or working conditions and other aspects of env

(j) to promote co-operation among scientific and professional groups w

(l) to promote maternal and child health and welfare and to foster the a

(m) to foster activities in the field of mental health, especially those affec

(n) to promote and conduct research in the field of health;

(o) to promote improved standards of teaching and training in the healt

(p) to study and report on, in co-operation with other specialized agenc

public health and medical care from preventive and curative points o

(q) to provide information, counsel and assistance in the field of health;

(r) to assist in developing an informed public opinion among all peoples

(s) to establish and revise as necessary international nomenclatures of d

(t) to standardize diagnostic procedures as necessary;

(u) to develop, establish and promote international standards with respe

Source: Article 2 of WHO’s Constitution.28

constituencies. Both boards would be executive committees

of the World Health Assembly where all member states

would continue to provide ultimate oversight. Separate

‘governing bodies’ units could support each of the two boards

given differing needs, but administrative staff could be

shared for efficient general management, internal oversight

and ombudspersons. Regional offices with their outdated

geography-based membership groupings would shed their

political stewardship functions e functions which are

themselves becoming increasingly irrelevant in a globalized

world where distance no longer constrains diplomatic activ-

ities and proximity rarely shapes common interests e and

transform into purely technical bureaus that could then more

harmoniously integrate with and report to WHO

headquarters. WHO’s technical secretariat could then either

continue using these bureaus to serve specific geographic

needs or they could allocate responsibility for different

functions and policy domains to different regional and

country offices. Or alternatively, WHO’s formal regional

structure could be dismantled, with member states in each

region deciding for themselves whether to have a regional

health body, what its functions would be, and how they

would fund it. Either way, importantly, the two chief officers

must have centralized authority for appointing all staff who

report to them e including potential regional directors and

heads of country offices e ensuring singular but distinct

points of accountability for technical and political steward-

ship operations (see Fig. 1 for a stylized organigram based on

WHO’s existing clusters, regions and support units).

O as written in Article 2 of its constitution.

ealth work;

ations, specialized agencies, governmental health administrations,

appropriate;

s;

ommendations with respect to international health matters and to

and are consistent with its objective;

essary aid upon the request or acceptance of Governments;

s, health services and facilities to special groups, such as the peoples

s may be required, including epidemiological and statistical services;

ther diseases;

ecessary, the prevention of accidental injuries;

re necessary, the improvement of nutrition, housing, sanitation,

ironmental hygiene;

hich contribute to the advancement of health;

bility to live harmoniously in a changing total environment;

ting the harmony of human relations;

h, medical and related professions;

ies where necessary, administrative and social techniques affecting

f view, including hospital services and social security;

on matters of health;

iseases, of causes of death and of public health practices;

ct to food, biological, pharmaceutical and similar products;

Fig. 1 e Proposal for Splitting WHO in Two. A stylized organigram based on WHO’s existing clusters, regions and support

units. The existing Executive Board and secretariat would be divided into technical and political boards and secretariats,

respectively, which would each report up to the World Health Assembly. There could be separate board support and

communications units, but otherwise administrative staff could be shared for efficient general management, internal

oversight and ombudspersons. Regional offices are represented as having shed their political stewardship functions and

integrating with the technical secretariat that reports up to a chief technical officer and the Technical Board. (Alternatively,

WHO’s regional offices could be dismantled, with member states in each region deciding for themselves whether to have a

regional health body, what its functions would be, and how they will fund it.) The acronyms in this organigram are those

currently used by WHO.

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 8 8e1 9 4192

Implementation of the proposed reform

Such bold changes can be promulgated by revising WHO’s

constitution or adopting new international law, but most of

them can also be achieved with far simpler implementation

mechanisms.27 For example, with only a majority vote, the

World Health Assembly can create a new Article 18 sub-

agency and populate it with WHO’s existing technical func-

tions. Remaining units could then serve as the political

stewardship secretariat. Alternatively, the World Health As-

sembly can pass a clarifying resolution,28 as they did in 1998,24

returning the Executive Board to its technical origins and

requesting the Director-General to create a new political

stewardship secretariat that would report directly to the

World Health Assembly’s President. In this way, small crea-

tive changes can have transformative effects.

But ultimately, no matter which proposals are imple-

mented, structural governance reforms are merely a start.

Even the most formalized, legally-binding revisions require

complementary changes in culture. In the case of enhanced

autonomy, for states, that means respecting this autonomy

and respecting Article 100 of the UN Charter, which prohibits

government officials from giving instructions to international

civil servants or otherwise influencing them in the discharge

of their responsibilities.29 For WHO staff, that means a culture

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 8 8e1 9 4 193

change towards heightened transparency and accountability

for both process and outcomes, evincing technical or political

stewardship proficiency (whichever the case may be) and

justifying enhanced autonomy. For along with greater au-

tonomy comes fewer opportunities to blame others like

member states for setbacks. Stronger mechanisms for inde-

pendent auditing, monitoring and oversight will be needed to

reward remarkable results and penalize poor performance.

The quality of WHO’s technical activities must especially be

high, matched by equally strong willingness to disagree with

political masters and courage to be assertive should intellec-

tual honesty require it. This, most importantly, includes high-

level staff resigning when their autonomy is threatened.

Safeguarding independence and professional integrity re-

quires it.

Next steps and considerations for movingforward

Member states have many good choices they can make in

reforming WHO. It is a most-important organization with

great potential. The status quo, however, which keeps WHO

constrained by outdated institutional arrangements, is not

the right choice. The organization needs to modernize its

governance as many countries have already done with their

national public health agencies and other domestic health

functions. WHO needs to be structurally redefined; divided

into two autonomous divisions, corresponding to its tech-

nical and political stewardship functions. Such bifurcation

would undoubtedly be difficult, messy, and contested, but

then WHO will be better positioned to fulfil its mandate as

both the world’s public health authority and platform for

global health negotiations, which is in everyone’s interests.

The current WHO reform process will only achieve real

progress if member states elevate their ambitions. Consid-

ering bolder proposals for change, like this one, would be a

good start, even if the full implementation of this proposal

may be infeasible and the proposal mostly serves to challenge

prevailing assumptions, encourage critical debate and facili-

tate new understanding about the problem at hand. Bold

proposals can also help point to and inform more realistic

options, such as ring-fencing WHO’s particularly technical

units (or those most prone to political interference) like those

responsible for the Codex Alimentarius and International

Classification of Diseases, or separating out very specific

functions as was done for cancer research through creating

an Article 18 sub-agency in a different city away from

headquarters.

Other multilateral institutions have already taken steps in

this direction. The UN Environment Programme and World

Meteorological Organization established an independent sci-

entific body to study climate change in 1988 (i.e., Intergov-

ernmental Panel on Climate Change), the UN Children’s Fund

set up a global research office in Florence that same year (i.e.,

UNICEF Innocenti Research Centre), and in 1999 the UN

Educational, Scientific & Cultural Organization created an

arms-length agency for data collection and analysis in Mon-

treal (i.e., UNESCO Institute for Statistics). The UN Human

Rights System benefits from the work of functionally

autonomous permanent expert committees and independent

special rapporteurs who operate frombases around theworld.

States’ inability to act on WHO’s institutional design chal-

lenges will only lead them and non-state actors to continue

bypassing the organization through the creation of new en-

tities as they have done over the last 15 years, some of which

would surely be more effective if part of it. One striking

example is the creation of IHME at the University of Wash-

ington, not WHO, which in reality operates as the world’s

global health monitoring institute without any formal links to

WHO, governments or the multilateral system. An indepen-

dent and autonomous monitoring institute within WHO

would have been a better alternative, but member states and

the secretariat have thus far not seen these issues clearly.

Moving forward, the key will be to mobilize those advo-

cates and decision-makers who have the audacity to demand

more from WHO, or, alternatively, to look outside WHO for

what this agency cannot deliver. Continued progress in global

health depends on it.

Author statements

Acknowledgements

SJH is financially supported by the Canadian Institutes of

Health Research and the Trudeau Foundation. Thank you to

Mohsin Ali, Charles Clift, Julio Frenk, Robert Marten, David

McCoy, Benjamin Mason Meier, Suerie Moon, Michael Reich,

Sarah Rostom and Suwit Wibulpolprasert for feedback on

earlier drafts of this paper.

Ethical approvalNone sought.

FundingNone declared.

Competing interestsSJH was previously employed by WHO. JAR is currently Board

Chair of WHO’s Alliance for Health Policy & Systems Research

and serves on the Scientific Oversight Group of the Institute

for Health Metrics & Evaluation.

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