As per its constitution, The World Health Organization (WHO) is “the directing and coordinating authority on international health work” (WHO, 2013:1). As presented in the report mapping WHO’s role in global health governance (GHG), over time there have been changes in how it is approached, and these changes also impact upon the power limits of WHO.
At its origins, GHG represented the ad hoc negotiations between countries conducted with the aim of protecting people’s health, especially with respect to communicable diseases. WHO emerged as an international institution which marks a more formal shift in approaching aspects of health at a cross-national level (WHO, 2013). One of its strengths therefore emerges from its strong links with the formalisation of GHG initiatives, and from the tradition and status as initiator it has in the field.
WHO remains the organisation which carries the coordinating and directing role in achieving greater coherence in global health by enabling the various actors to participate effectively (WHO, 2013).
As the health governance agenda has changed to include multiple voices, global health is no longer only a matter for nation states. New actors are participating, from civil society networks to national and transnational corporations and international financial institutions. As shown by Ng and Ruger (2014:2), this represents a shift from International Health Governance (IHG), which was “relatively simple, with a small cast of actors and clear lines of responsibility”, where the need for coherent coordination was lower to GHG. In the new context of rapid globalisation and increased economic interdependence, WHO needs to ensure primacy of member states whilst simultaneously engaging other stakeholders without exposing itself to vested interests. Whilst multiple participants may mean multiple resources invested in achieving global health aims, it also means a redistribution of power in GHG. It may be argued that, as the number of participants grows, the strength of the WHO narrows. Ng and Ruger (2014:4) argue that “The rise of non-state actors and major global health initiatives driven by public-private partnerships, foundations, G8, and other non-UN/WHO entities has diminished the importance of WHO and health-related UN organisations in GHG”. WHO is still the governing authority in GHG, but only owing to the absence of a better alternative.
As in the report of the Commission on Social Determinants of Health (CSDH, 2008), health is no longer seen as being solely an issue relevant to the health sector itself, but one which needs to be addressed in a global coherent cross-sectorial approach, since it is impacted upon by factors which stretch well beyond the health sector. One of the consequences of this acknowledgement is that institutions whose primary objectives are connected to other sectors (e.g. economic) now become influential participants in health policy. Although they do not necessarily have a tradition and a formal leading role in global health governance, their strength is incontestable as it emerges from solid resources. Balstad and Røttingen (2010:60) support this view as they indicate that “There is, as always, reason to believe that influence follows the money around, and that WHO’s efforts in strengthening global health systems sooner or later will meet opposition from very powerful global actors”. This puts the WHO in a vulnerable position, and it is seen by critics (Ng and Ruger, 2014) as being liable to bilateral influence, and to pressure from the political sector.
Other recognised weaknesses of the WHO are that: It has no enforcement powers, it is too bureaucratic and insufficiently connected with civil society, and it holds conflicting roles as advocate, advisor and evaluator (Ng and Ruger, 2014). All these aspects are factors which limit its effectiveness.
Many health issues are influenced by decisions taken in other sectors such as those shown by the CSDH (2008), and although identifying the network of contributing factors – an effort which has already been made - is an important step forward in addressing the issues, the remaining challenge is to orchestrate a coherent response across societies and sectors. The WHO finds itself dependent on limited resources and forced to “make strategic and selective use” of these resources in order to “maximize the impact given the wide range of institutions involved” (WHO, 2013: 6).
Balstad and Røttingen (2010) point out that WHO’s aim to collaborate with other international partners in order to strengthen health systems describes a broad based initiative, a horizontal one, which will inevitably conflict with vertical integrated health initiatives. The collision needs to be acknowledged, regardless of whether the vertical initiatives are pertinent or not. It is the possibility for conflict to arise which is emphasised, because conflict may push WHO into the middle of a fight for power that they might not win.
Balstad J and Røttingen J.A. (2010). Examining the Global Health Arena: Strengths and Weaknesses of a Convention Approach to Global Health Challenges. Report from the Norwegian Knowledge Centre for the Health Services No. 12–2010. Oslo: National Knowledge Centre for the Health Services.
Ng, N. and Ruger, J. (2014). Global Health Governance at a Crossroads. Global Health governance. 3(2): 1-37.
WHO. (2013). WHO’s role in global health governance. Report by the Director-General. [Online] Available at: http://apps.who.int/gb/ebwha/pdf_files/eb132/b132_5add5-en.pdf [Accessed 15 December 2018]