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JAMA Forum
April 30, 2020

COVID-19 Reveals Urgent Need to Strengthen the World Health Organization

Author Affiliations
  • 1Georgetown University Law Center, Washington, DC
  • 2Director, World Health Organization Collaborating Center on Public Health Law and Human Rights
JAMA Health Forum. 2020;1(4):e200559. doi:10.1001/jamahealthforum.2020.0559

From the time China reported a novel coronavirus to the World Health Organization (WHO) on December 31, 2019, it took barely 4 months to become a pandemic, killing hundreds of thousands, and growing daily. It is now clear that the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had been circulating in Wuhan, China, for weeks before China reported it to the WHO, and that authorities hid information. China maintained SARS-CoV-2 was not readily transmissible between humans. The WHO published China’s data, but without independently verifying their accuracy.

President Trump subsequently blamed the WHO for its slow and “China-centric” response. On April 14, 2020, he announced a suspension of US voluntary contributions to the agency.

Although the WHO was unable to verify the Chinese data, it was proactive, including widely sharing the genomic sequencing of the virus with international scientists. On January 30, 2020, the WHO declared coronavirus disease 2019 (COVID-19) a global health emergency, urging rigorous containment including testing, contract tracing, and quarantine. Broad criticism of the organization is unfounded, and is particularly damaging because the pandemic is poised to deeply affect sub-Saharan Africa. That said, legitimate concerns about the WHO include its reluctance to insist China allow a robust WHO team on the ground and its praising of China’s transparency.

The crisis now unfolding could also become a historic opportunity to strengthen the WHO. Reforms must start with recognizing the global public good achieved by the WHO.

Protecting the World From Global Health Threats for More Than 70 Years

Formed in 1948 as the first United Nations (UN) specialized agency, the WHO has helped protect humanity from global health threats. Its early work prioritized tuberculosis and malaria, as well as sanitation, maternal and child health, and nutrition. The WHO’s most celebrated achievement was eradicating smallpox in 1980. Today, the WHO and its partners are on the verge of eradicating wild-type polio, now confined to Afghanistan and Pakistan. After eliminating malaria from more than 2 dozen countries during the 1950s, the organization now aims to reduce 90% of malaria cases and related deaths by 2030.

The WHO has responded to public health emergencies of international concern, authorized under the International Health Regulations (IHR) in 2005, including the 2009 pandemic influenza A(H1N1) virus, polio in 2014, Zika in 2014, Ebola in 2014 and 2018, and COVID-19 in 2020. After the West African Ebola epidemic, the agency revamped its response capacity, forming a Health Emergencies Program and launching a health emergencies fund.

Beyond infectious diseases, the WHO monitors global health trends, conducts research, sets standards, and provides technical support. The agency’s work ranges from noncommunicable diseases, nutrition and obesity, to mental health, road safety, and antimicrobial resistance. Importantly, the WHO provides relief for the hundreds of millions who suffer from extreme poverty. Responding to the UN’s Sustainable Development Goals, the WHO devised a 5-year “triple billion” strategic plan: 1 billion more people benefitting from universal health coverage, 1 billion more people protected from health emergencies, and 1 billion more people with improved overall health.

Creating the WHO the World Needs

The WHO has achieved so much even with paltry funding. Out of the COVID-19 pandemic, the WHO could be reimagined as a stronger, more responsive international agency. Among the most crucial reforms are funding, member state compliance with norms, and political support.


The WHO is chronically underfunded, given its comprehensive global mandate. Its biennial 2020-2021 budget is $4.8 billion—similar to a large US hospital, and about $2 billion less than the US Centers for Disease Control and Prevention’s annual budget.

Sustainable investments in the WHO would more than pay for themselves. Consider that the COVID-19 stimulus packages in the US cost trillions, compared with scant funding devoted to global health. Investments in any aspect of the WHO’s portfolio would reap returns in healthy lives and economic gains through increased productivity. Even raising the agency’s budget in line with the US Centers for Disease Control and Prevention’s budget would more than double the WHO’s budget. The WHO should undertake a transparent planning process to estimate realistic budgets needed to achieve tangible health benefits.

Not only is the WHO’s budget too low compared with its global mandate, but it also is too reliant on voluntary funds. Not even $1 billion of the WHO’s 2018-2019 budget came from member states’ mandatory assessments, with the rest from voluntary, earmarked funding. The WHO’s budget would be more predictable if a higher percentage came from mandatory assessments. Countries could commit to mandatory assessments to cover half the organization’s budget.

Member State Compliance With WHO Norms

The WHO suffers weaknesses common for international organizations: limited compliance with norms and few tools to enforce norms. Under the legally binding IHR, member states agreed to develop core health capacities to detect and respond to public health emergencies. The IHR entered into force in 2007, yet compliance remains spotty.

The WHO has tools to improve compliance, though at a political risk. Under article 7 of the WHO’s constitution, member states that fail to meet obligations may have their voting privileges or other services suspended. The WHO director-general could seek World Health Assembly approval to invoke article 7 in cases of severe noncompliance. New compliance-enhancing tools might include WHO funding to incentivize member states to meet IHR duties, especially health system capacities. As a post-Ebola commission proposed, the International Monetary Fund could incorporate national preparedness into its macroeconomic assessments, which affect countries’ access to capital. Reform of the IHR could specify that noncompliance could amount to an article 7 violation. And countries could bring cases of unjustified trade restrictions to the World Trade Organization. Civil society could also monitor member state compliance and issue shadow reports, much like on human rights compliance.

Political Independence

The WHO relies on governments for funding and support. The agency should not have praised China’s transparency when it suppressed information on community transmission. Yet the WHO’s dilemma is clear: it relies on member state cooperation, including access to a member state’s territory to get the WHO’s experts on the ground.

The WHO director-general must have freedom to act in the best interest of public health and science without political interference. Solutions are difficult but must be found.

Move the WHO Headquarters to Africa

Although high-income countries used their own resources to respond to COVID-19, the pandemic is poised to affect low- and middle-income countries. The WHO’s historic value-added has been primarily in low- and middle-income countries. The location of the WHO headquarters in Geneva, Switzerland, the epitome of a rich country in the heart of Europe, sends the wrong signal. If its headquarters were moved to sub-Saharan Africa, the WHO would be in a better position to respond rapidly where its technical assistance is needed most. Whatever the challenges, moving its headquarters to Africa would be a powerful symbol of the WHO’s commitment to the world’s poorest communities, making the organization seem less aloof and more relevant in the modern world.

A WHO That the World’s People Deserve

Governments have the WHO they deserve, an agency hobbled by chronic underfunding and weak political backing. It is little wonder that successive WHO directors-general have found it difficult to speak truth to power. With the devastating toll COVID-19 is taking across the world, it is past time to give the people of the world the WHO they deserve.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Lawrence O. Gostin, JD, Georgetown University Law Center, 600 New Jersey Ave NW, McDonough 568, Washington, DC 20001 (gostin@law.georgetown.edu).

Conflict of Interest Disclosures: None reported.

4 Comments for this article
Parkinson's Law
Paul Nelson, MS, MD | Family Health Care, P.C. retired
Parkinsons law refers to the growth of bureaucracy within an organization. It seems that the governance of WHO over the last 25 years has not led to a steadily high level of performance. I suppose that it might depend on what events might be chosen as a measure. Several years ago, WHO finally had access to our world-wide influenza monitoring data as a basis to recommend the influenza immunization constituents to be used worldwide during the next calendar year beginning in the Southern Hemisphere. Presumably, this would prevent a pandemic of influenza (so far so good) and reduce influenza mortality. I know of no evidence that world-wide influenza has been improved. Furthermore, the year to year effectiveness of the WHO constituted seems pegged at around 60%, and our nation averages about 60,000 influenza deaths annually. So, has the WHO influenza immunization management actually impeded the research for developing a truly effective vaccine? Remember, most immunizations are 95%+ effective (oh yes, the pertusis immunization isn't quite at the level)?

So, I look on the WHO website and observe that their annual meetings apparently occur in sumptuous surroundings? I only mean to imply that for most complex institutions that their employment practices usually increase based on the resources available. Furthermore, decentralized institutions tend to have a better connection with the object of their existence, and in the case of WHO, a better opportunity to connect with the realities of their institution's obligations.

I vote for a study of WHO to inform a better alliance structure for its governance, funding, and a slowly stable process (5-7 years) of decreasing support by the USA until an effective reorganization occurs (viz 6 continent groups: North America, South America/Antarctica, Europe, Africa, Asia, Oceania/Australia/Japan/So Korea/Taiwan).
Contribution to Global Health of WHO and its Regional Office for the Americas
Jose Ramiro Cruz, Virology/Immunology | Independent Consultant
The World Health Organization (WHO) supports 194 countries through six regional and 150 country offices, in addition to its headquarters in Geneva. The Pan American Health Organization (PAHO), created as the Pan American Sanitary Bureau in 1902 with the main purpose of controlling infectious diseases in this continent, serves since 1949 as the Regional Office for the Americas. During its 118 years of existence, PAHO has implemented WHO policies and programs in Latin American and the Caribbean. It has also provided scientific and technical leadership in the development of global strategies with permanent implications for public health. For instance, the initiatives for eradication of smallpox (1), of wild poliovirus (2), and the World Immunization Week were all developed and initiated in the Americas. Of current interest, the first and so far only proven beneficial clinical effect of convalescent plasma on viral infections was reported in Argentina in 1979 (3).

In addition to its work on vaccine-preventable diseases, with the support multiple partners (4), PAHO works with in blood transfusion safety, aiming at preventing transfusion-transmission of HIV, hepatitis B and C, HTLV, T. cruzi and other pathogens locally prevalent, and at promoting better patient management, with emphasis on the reduction of maternal mortality. Disaster preparedness and response are also a priorities for PAHO. (5). PAHO promotes health in 52 countries and territories in collaboration with over 180 specialized centers, 86 of which are in the USA and 27 in Canada. PAHO has supported research in several centers, one being the Institute of Nutrition of Central America and Panama (INCAP), created in 1949. Researchers at INCAP were pioneers in studying the epidemiological, microbiological, nutritional and protective effects of breastfeeding and identified what are now called pre and probiotics, protective sIgA, and immune-modulating molecules in breast milk. INCAP played a central role in the control of outbreaks of Shigella dysenteriae 1 in Central America in the 1960s and 1990s, and in the surveillance and control of cholera in 1991. The virology laboratory at INCAP served as the Reference for Polio Eradication in Central America since 1987, after it reported that Sabin-vaccine derived polio 2 was capable of reverting to virulent and of causing outbreaks of paralytic disease among under-vaccinated children after multiple cycles of natural transmission (6). This epidemiological observation, made before the advent of nucleic acid testing, was later proven right with the use of molecular analyses (7, 8).   

The continued financial support to WHO and PHO is vital for global health.


1. https://iris.paho.org/bitstream/handle/10665.2/29314/16_11.pdf?sequence=1&isAllowed=y 
2. https://www.ncbi.nlm.nih.gov/pubmed/12280449
3. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(79)92335-3/fulltext
4. https://www.gatesfoundation.org/Media-Center/Press-Releases/2000/12/Blood-Safety-Program-Receives-Grant
5. https://www.paho.org/disasters/index.php?option=com_docman&view=download&category_slug=books&alias=431-newsletter-83-april-2001&Itemid=1179&lang=en
6. https://www.ncbi.nlm.nih.gov/pubmed/3442717
7. https://academic.oup.com/aje/article/175/1/86/133359
8. https://academic.oup.com/aje/article/175/1/86/133376).
CONFLICT OF INTEREST: I was Regional Advisor for Laboratory and Blood Services, and Senior Advisor, Health Technologies for Quality of Care PAHO Washington, 1994-2011. I was Head, Program of Infection, Nutrition and Immunology. INCAP, Guatemala, 1981-1993.
A Return to a Human-centric Approach Towards Global Health Security
Tsung-Ling Lee, SJD. LL.M. BMedSci | Taipei Medical University
As of May 5, Taiwan has yet to receive an invitation letter to attend the annual World Health Assembly (WHA) despite its widely reported success in the containment of the COVID-19 pandemic. This is largely due to political pressure from China. However, the exclusion of Taiwan from participating at the WHA is inconsistent with the spirit of WHO, which is the promotion of health for all. While WHO is an intergovernmental agency, at the end of the day, it is the lives of individuals around the world that matters. It is by improving the health of individuals that gives the agency’s moral legitimacy. Accordingly, reform of the WHO in general, and the International Health Regulations (IHR), in specific – must place individuals at the centre, above and beyond politics. Solidarity cannot be forged without recognizing the complex interdependence that shapes and informs global health. I agree with Dr Paul Nelson on the need for a reform study based on six continent groups. Likewise, a functional IHR, the global architecture for international infectious disease, must also go beyond the current limitation where infectious disease control is conceived as purely a matter of the nation-state. Operating IHR within the parameter of the nation-state has proven disastrous, perpetuated by national interests with grave human costs. A return to a human-centric approach that places individuals at the core of global health security regime would only then meaningfully reflect the scientific reality that viruses know no borders.
WHO Reform Might Better Involve the UN Security Council
Victoria Sutton, J.D., Ph.D., M.P.A. | Texas Tech University School of Law, Center for Biodefense, Law & Public Policy
The World Health Organization is in need of reform but the World Health Assembly has rejected any amendments to the WHO constitution since its beginning. Despite its weak form of enforcement, the constitution is strongly collaborative and uses international diplomacy as its best enforcement tool.
However, I do not believe the problem can be changed by increasing WHO’s power, or throwing more money at the problem.

The relationship between the various organs of the United Nations is one of its greatest strengths. Almost every aspect of human existence is addressed by one of the dozens of units in the
UN. When the WHO declares a public health event as a “public health emergency of international concern” (PHEIC) it heightens the urgency (this is the term used in the International Health Regulations, and I believe what the author was referring to when he wrote “global public health threat”). A PHEIC by definition affects other countries, which becomes a global security issue, and likely one of national security for each nation affected. This signals the potential involvement of the UN Security Council, to potentially take action that will be enforceable. Raising the issue to this political level will give the public health threat the attention it deserves, and empower the WHO. The UN Security Council has permanent members who can veto any decision from the UN Security Council. China is a permanent member, and so is Russia. Despite their ability to veto any UN Security Resolution, the level of attention this will receive would create additional pressure on a recalcitrant and non-compliant member-nation.