The World Health Organization in crisis
The World Health Organization faces a deepening crisis of funding, authority and relevance as alternatives emerge for disease surveillance and emergency response.
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- U.S. withdrawal has deepened the WHO’s budget shortfall
- The WHO structure no longer corresponds to current health risks
- Regional and private networks are assuming a larger global health role
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Confidence in the World Health Organization (WHO) plummeted after multiple missteps in addressing the Covid-19 outbreak. Reform efforts are underway, but budgetary, bureaucratic and political obstacles make even marginal progress difficult to achieve. A variety of alternatives to the WHO’s outmoded structure may promise greater benefits for global health.
Improvements in global health have fundamentally changed the nature of the risks facing the world since the WHO was established in 1948. At that time, infectious and parasitic diseases such as smallpox, malaria and tuberculosis caused most deaths worldwide. Today, however, the leading causes of death are chronic, noncommunicable conditions such as cardiovascular disease, cancer, diabetes and respiratory illnesses, which together account for about three-quarters of global deaths.
Yet concern about global capacity to manage pandemics remains widespread. Dozens of pathogens pose outbreak risks, including Ebola, Marburg disease, SARS, cholera and coronavirus. Joy Phumaphi, co-chair of the Global Preparedness Monitoring Board, told CBC News in May: “We are at a crucial time in the history of pandemic preparedness as a global community … [W]e definitely are not ready for the next pandemic.”
Such expressions of alarm appear to bolster the WHO’s pleas for additional funding. The organization is facing a budget deficit of nearly $1.9 billion for 2026-2027. The United States contributed nearly $1 billion in 2022-2023, but the Biden administration left office without paying $130 million in dues for 2024. President Donald Trump subsequently issued an executive order halting all payments to the WHO, citing its “mishandling of the Covid-19 pandemic … and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states.”
- Founded
- April 7,
1948 - Members
- 194
states - Global presence
- Geneva headquarters6 regional offices
Offices in more than 150 countries
How the WHO is governed
What the WHO does
- Sets international standards for disease surveillance and reporting
- Develops treatment protocols
- Establishes standards for vaccine production
- Coordinates global health data
- Declares public health emergencies
- Coordinates international responses to health emergencies
- Provides technical assistance to countries
- Runs programs targeting HIV/AIDS, malaria, tuberculosis and polio
Other experts say that global health would be better served by a more decentralized network of disease surveillance and emergency response. Indeed, the number of organizations challenging the WHO’s dominance is increasing, including governmental and nongovernmental systems, academic centers, corporate entities and military operations.
Whereas the WHO was designed to leverage cooperation among nations, the erosion of multilateralism has diminished its influence and efficacy. As noted earlier this year by Michael Moller, a former undersecretary general of the United Nations, “The truth is uncomfortable but unavoidable: the international system designed 80 years ago is no longer fit for purpose.”
Post-Covid reforms
The WHO’s mishandling of the Covid-19 outbreak prompted widespread calls for structural reforms. The organization’s global alert protocol failed to distinguish between epidemics, pandemics and an array of other disease outbreaks – each of which requires different responses. In fact, there was no definition of “pandemic” within the International Health Regulations (IHR), which governs the WHO’s declaration of a Public Health Emergency of International Concern (PHEIC).
In response to the criticism, the WHO in 2024 amended the IHR to include a new type of global alert: a “Pandemic Emergency.” Proponents hope that the new tier of emergency declaration will clarify when an outbreak is more serious than an epidemic or the other health emergencies covered by a PHEIC.
- Base programs$4.3 billion
- Emergency operations and appeals$1 billion
- Polio eradication$771 million
- Special programs$169 million
How base programs are funded
More than 85% of voluntary funding is earmarked for specific programs
Largest voluntary contributors
The IHR amendments also created a “Coordinating Financial Mechanism” in the name of “solidarity and equity” for lower-income countries. Many developing countries had complained that the IHR lacked a mechanism to ensure the sharing of vaccine resources or to develop local manufacturing capacity. The new measure is intended to assist low-income states with obtaining medicines, vaccines, diagnostics and a variety of other health technologies. It also expands the requirements of member states to share information about and notification of disease outbreaks. However, it does not impose enforceable obligations on governments, nor grant the WHO authority to compel cooperation.
Additional reforms are in process. In February 2022, WHO member states convened an Intergovernmental Negotiating Body to draft a freestanding Pandemic Agreement. The agreement led to the creation of a Pathogen Access and Benefit Sharing system (PABS) in 2025.
A PABS working group was established in 2024 to negotiate how the system could ensure rapid sharing of pathogen samples with pandemic potential for the development of diagnostics and therapeutics, and the “fair and equitable” sharing of benefits arising from such developments. Agreement on the PABS system will be necessary before member states can proceed to ratification of the full Pandemic Agreement.
As drafted, the agreement does not grant WHO officials authority to mandate requirements, travel bans, vaccine mandates or lockdowns.
Challenges and obstacles to WHO reform
No expert or credible critic accuses the WHO of nefarious motives or lacking good intentions. Thousands of WHO staff are recognized as hard-working and dedicated to saving lives. But even the organization’s most ardent supporters acknowledge that its efficacy is undermined by structural impediments.
The WHO’s reliance on voluntary contributions – the largest source of funding – means spending is driven by donor interests and not the agency’s priorities or goals. The organization exercises discretion over less than 10 percent of all voluntary contributions, and pandemic preparedness does not top donors’ lists.
The organization also lacks enforcement authority over member nations. The IHR require countries to report outbreaks, but the WHO cannot enter a country to investigate a suspected outbreak without government permission; it relies on data from member states rather than independent verification. It cannot impose sanctions against countries that withhold data or fail to report a disease outbreak.
The WHO operates on a one-country, one-vote governance structure, without regard to a nation’s relative disease burden or financial contribution. Thus, any single country can block the consensus long preferred by the World Health Assembly as necessary for political legitimacy, or can force compromises on policies otherwise favored by most members.
President Donald Trump subsequently halted U.S. payments and initiated the country’s withdrawal from the WHO
Spending under scrutiny
Senior directors
201739
202475
The one-vote, one-state structure may have worked well enough in 1948, when there were just 55 countries under the WHO banner. Today, however, there are 194 member states divided by a host of contentious issues. Geopolitical realignment and deglobalization have eroded the multilateralism of yesteryear, and with it has come a weakening of the WHO’s moral authority.
The WHO comprises myriad experts, advisory panels, working groups and emergency committees. Its procedural complexity is compounded by its dozens of regional and field offices. This vast bureaucracy precludes quick action, and maintenance costs overwhelm the proportion of expenditures for disease control and prevention.
The organization was initially structured around disease surveillance and emergency response. But communicable diseases, while problematic, constitute a small proportion of current global health risk. Today, the primary causes of death are chronic, non-communicable conditions such as cardiovascular disease, cancer, diabetes and respiratory illnesses, which together represent about three-quarters of global deaths. All of these require different approaches for treatment and prevention.
Alternatives to the WHO in global health
Global health has undergone enormous changes since the founding of the WHO in 1948 – the WHO’s structure no longer functions effectively in a world transformed by geopolitical shifts. Fortunately, the provision of global health services now extends well beyond the WHO. A variety of alternatives have emerged to fulfill the roles in which the WHO can no longer adequately perform.
The Measles & Rubella Partnership. Comprising, in addition to the WHO, the American Red Cross, the Gates Foundation, Gavi, the United Nations Foundation, the U.S. Centers for Disease Control and Prevention and UNICEF, the alliance was created to eradicate measles and rubella.
Regional public health agencies. Africa CDC, the European Centre for Disease Prevention and Control, and the G20’s Joint Finance-Health Task Force. These and other regional bodies increasingly act as first responders to disease outbreaks, able to render aid quickly and adapt to local conditions.
Financing. The Gates Foundation, the World Bank’s Pandemic Fund and the Coalition for Epidemic Preparedness Innovations.
Vaccine access. Gavi, the Vaccine Alliance handles vaccine procurement and distribution logistics at scale.
Independent monitoring and AI-driven surveillance. The Global Preparedness Monitoring Board works to ensure preparedness for global health crises. Systems such as BlueDot and ProMED use artificial intelligence and open-source data to flag outbreak signals.
Scenarios
Most likely: WHO retreats to a narrower, more technical role
The loss of U.S. support for the WHO, coupled with the lack of structural reform and continuing inefficacy, would cause the organization’s influence – and funding – to wane even more. Deepening deficits would force the organization to curtail operational activities and to focus instead on normative functions such as data collection and technical assistance.
Many of the WHO’s operational functions would be assumed by public and private organizations that are better suited for disease surveillance and outbreak response. Such efforts would receive additional support from the U.S. as it shifts its global health focus to bilateral and regional partnerships, the private sector and nongovernmental organizations.
In America’s absence, China is assuming greater influence in setting WHO policies, but its interests, as well as those of Russia, are likely to diverge from those of the European Union, India, Africa and other states – making consensus on policies harder to achieve and thus worsening politicization of the WHO. That could further undermine the WHO’s performance.
Should the WHO retreat from operational activities, the EU and other countries would be forced to ramp up their own health initiatives, either independently or regionally, or in partnership with the private sector and/or nongovernmental organizations.
Less likely: A new pandemic drives structural reform
A major pandemic might rouse the World Health Assembly to initiate substantive structural reforms, and to incorporate enforcement mechanisms within the IHR. With greater attention to accountability, the assembly could reorder program priorities and realign spending to focus on the gravest threats. Such reforms, in conjunction with a change in U.S. administration, could bring America back into the WHO fold, albeit conditionally.
National interest might also reverse the erosion of multilateralism, such as the U.S. seeking to counter China’s growing influence within the WHO; Russia aiming to maintain a point of global leverage as its fortunes weaken vis-a-vis the protracted Ukraine conflict; EU efforts to offset China’s increased influence (in the absence of the U.S.) and to forestall the decentralization of global health; and India and other developing nations that want to sustain access to vaccines and other medical resources through the WHO.
Least likely: Decentralized networks replace the WHO
As dysfunction increasingly plagues the WHO, it would be effectively replaced by bilateral and regional health partnerships, privately funded initiatives and AI-assisted disease surveillance networks, among other alternatives.
Political fragmentation would likely devolve into a China-centric bloc (with or without Russia); a Western-aligned bloc (with or without the U.S.); and an African bloc. Cross-cutting agreements between them could be reached to coordinate pandemic responses, but each would maintain their independence.
Decentralization could improve the efficiency of emergency responses and help to tailor assistance to the diverse needs of regional and local populations. Conversely, the lack of countervailing political forces within blocs dominated by a handful of nations could subject global health to even greater politicization and relegate powerless countries to the margins of global health.
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