Introduction: COVID-19 and WHO: Global institutions in the context of shifting multilateral and regional dynamics

Since the identification in late 2019 of a new coronavirus causing severe acute respiratory syndrome (now widely known as Covid-19) the World Health Organization (WHO) has unsurprisingly been a focus of critical international attention. Established in 1948 as a technical agency under the United Nations system, the WHO is ‘the directing and coordinating authority on international health work’ (WHO, 1948), with the power through the International Health Regulations (IHR) to determine a Public Health Emergency of International Concern (PHEIC) and mandated to lead the global response to such an event. Having declared COVID-19 a pandemic on 30 January 2020, its role has included gathering and analysing data from around the world, supporting clinical trials on drugs and vaccines, and providing technical guidance to countries. Since January, WHO has published numerous documents about COVID-19 covering topics such as

how to find and test cases, how to provide safe and appropriate care for people depending on the severity of their illness, how to trace and quarantine contacts, how to prevent transmission from one person to another, how to protect health care workers, and how to help communities to respond appropriately. (WHO, 2020a)

The agency updates these guidelines regularly and has provided many free online courses through the Open WHO platform. ¹

In this context, and to the astonishment of many long-term observers, the inevitable focus on the work of the WHO turned quickly to open criticism of the agency. This has come in particular from the Trump Administration initially in relation to WHO’s handling of China. While not the first time the WHO has been caught in the crossfire between discordant member states, it is unprecedented that an influential member state should leave the organization in the midst of a global health crisis or disease outbreak. The resulting scrutiny and fierce debate extends beyond the role or mandate of WHO, its response to COVID-19 or its capabilities for fulfilling its functions: it is more fundamentally about the role of politics in global health crises, against a background of geopolitical shifts, the changing nature of multilateralism and the rise of nationalist or populist politics within countries.

This Forum brings together an outstanding group of scholars, practitioners and advocates to reflect on WHO’s response to this complex global crisis within the context of broader conversations on global health, security and development, and contemporary threats to multilateralism and global solidarity. In this introduction, we highlight the key themes of the Forum articles, including the challenges to the mandate of WHO and the politicization of its role in the crisis, while also considering what a distinctive global social policy (GSP) perspective offers to this debate.

One of the main themes in GSP scholarship involves the idea of global social governance, that is, the mechanisms that enable the international community to address global social problems, through systems of global regulation across national borders and a globally agreed set of social rights (Deacon, 2007; Deacon et al., 1997). The role of WHO has significantly diminished from being the sole or even leading actor in the global health architecture, to becoming one among many actors in a more complicated institutional landscape. Nonetheless, the organization continues to play a key role, in ‘providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends’ (WHO, 2020b). It obviously plays a critical function in the management of infectious diseases, and has been applauded, for example, for its smallpox and polio eradication campaigns. But WHO has also been subject to repeated calls for reform to address a long list of perceived problems, from lack of authority and legitimacy, ineffectiveness, overly bureaucratic processes and lack of emergency response preparedness, to the politicization of the agency (Bort, 2020; Loewenberg, 2017; Ruger and Yach, 2009; Sridhar and Gostin, 2011). In the case of Ebola in West Africa, for example, WHO was deemed ineffective due to its delay in declaring a PHEIC (Kamradt-Scott, 2016; Moon et al., 2015).

In the context of COVID-19, WHO is being subjected to a similar tide of criticism, over whether it has responded appropriately and in a timely manner, as well as whether it has held the Chinese government – as one of its member states – properly accountable. To some observers, these criticisms reflect a tension in WHO’s identity: between its roles as an organization of Member States and as the world’s leading public health agency: Does it serve the interests of [some of] its members or does it prioritize global public goods and advocate for the world’s public health needs? The framing of this tension as a duality encompasses a number of ideas that are worthy of closer examination.

At first sight, this framing is fundamentally linked to the mission and mandate of the WHO. As a multi-lateral organization, established by a United Nations treaty among member states, and governed by the World Health Assembly (WHA) following the principal of one member one vote, its authority is based on consenting states agreeing to follow the institutional rules. In terms of its mandate, it is tasked with coordinating international health work (Article 2a) as well as assisting member states ‘upon request, in strengthening health services’ (Article 2c) and furnishing ‘appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments’ (Article 2d). WHO is therefore expected to serve its members’ interests and to act as a global health leader – but is there a contradiction between these roles? A closer look at how critiques are framed with reference to this duality suggests that arguments are in fact about (1) the role of politics and politicization and (2) the performance of WHO and whether it can carry out ‘all’ of its responsibilities.

In the context of Covid-19, as Kelley Lee notes in her Forum piece, the accusation of playing politics has become the ‘insult of choice’. She poses the dualism more clearly in these terms: ‘How then can WHO, mandated to be an ostensibly scientific and technical agency, navigate the choppy waters of international politics when fulfilling its role as the directing and coordinating body for health cooperation?’ Lee argues that the first step is acknowledging that a ‘politics-free WHO’, while frequently evoked as an ideal, has never existed in reality, and that global health and politics are inextricably intertwined. Once we define WHO as ‘a hybrid organization which must catalyse leadership in the health sciences and political practice in equal measure’, Lee explains, the real issue becomes how to ensure ‘good politics’. ‘Good politics’, she suggests, might be assessed in terms of principles of good governance (including transparency, accountability and participation); institutional arrangements with appropriate checks and balances; and normative values that serve as a basis of legitimacy and may bolster WHO’s political authority in relation to member states, other international organizations and non-state actors.

Since the 1990s, the global health landscape has been transformed through the involvement of an expanding group of actors. In addition to long-standing international NGOS (INGOs) such as Médecins Sans Frontières (MSF) or Oxfam, the period has seen the rise of public-private partnerships such as GAVI and the Global Fund, an increasing role for private philanthropies in global health, most notably the Bill and Melinda Gates Foundation, as well as the growing influence of for-profit companies such as the pharmaceutical and food industries. Regional organizations such as the European Union, Mercosur, ASEAN and the African Union have also encouraged cooperation among member countries on health matters, especially infectious disease management. Such pluralism has led some observers to question WHO’s role in an increasingly fragmented, crowded and uncoordinated global health space. An associated shift in financing sources and mechanisms, particularly the rising dependence of the WHO on extra-budgetary or earmarked funding, also impacts the power, autonomy and capacity of the organization, and gives some non-member state actors significant influence over the shape and priorities of the organization.

WHO has a variety of ways of engaging with non-state actors, including NGOs with official relationships, via Collaborating Centres, and through a variety of consultation processes on policies and standards. At the same time, cumbersome procedures exist to avoid conflicts of interest or inappropriate influence from industry. David Legge points to the limits and challenges to these various forms of engagement, particularly where powerful pharmaceutical companies and trans-national capital are involved, illustrating his point in particular with reference to the new Access to Covid Tools Accelerator (ACT-A or ‘the Accelerator’). Ultimately, however, he argues that the major failure of accountability is in fact of member states in their responsibilities towards global health governance.

These concerns over institutional, finance and governance arrangements relate to the second dimension implicit in the framing of duality: whether the agency is able to carry out its duties effectively or whether it is vulnerable to [particular] member state influence. As Chorev, Erondu et al., and Legge demonstrate in this Forum, there are significant constraints on WHO’s ability to ensure that countries abide by its policy decisions and guidelines. The IHRs, for example, stipulate that all countries should provide timely and accurate information to WHO, refrain from restricting trade and travel beyond such restrictions as authorized under the IHRs, and notify the WHO when they deviate from authorized measures. However, WHO lacks the mechanisms to enforce compliance. Furthermore, there are disincentives to compliance: as Nitsan Chorev points out, if reporting a disease outbreak to WHO leads to the imposition of travel and trade restrictions, countries may be reluctant to report. Thus, when member states do not adhere to the regulations, is this a reflection of WHO’s ‘capitulation’ to particular countries’ interests (political argument) or is it a consequence of weak institutional arrangements or enforcement mechanisms stipulated in the relevant treaties (technical/structural argument)? And what does this imply about the autonomy of WHO?

Erondu et al. address this debate in their argument for empowering the WHO to carry out its global leadership role, rejecting the duality between WHO’s role in global coordination and norm setting on the one hand, and its responsiveness to member states on their technical and policy priorities on the other. Legge goes one step further arguing that WHO should have a role both in providing global public goods and in assessing country performance. This can indeed be possible because, as Chorev reminds us, ‘international bureaucracies are strategic actors with their own organizational and normative goals and with some ability to shape or only partly adapt to states’ demands’. Ekpenyong and Soto Pacheco take a similar position, arguing that the WHO has forms of power that it can use: ‘for power redistribution between the global north and south through horizontal knowledge exchange and the incorporation of best practice examples from the global south’. COVID-19 provides an opportunity to incorporate southern knowledge as the norm into the global landscape, challenging representations of ‘helplessness and fragility of the global south’ as well as the narrative of a lack of expertise that needs to be redressed or filled by experts from the global north. Redressing such power inequalities may also start to counter the problem, vividly exposed by this pandemic that many ‘rich’ countries of the global north have come to see WHO as an organization mandated to support less developed countries but irrelevant to their own health systems or responses. It may be through the strengthening of international legal instruments, and going beyond the existing two (Framework Convention on Tobacco Control and International Health Regulations) that WHO can truly be the ‘directing and coordinating authority’ that it was designed to be, rather than a conduit for development assistance at the behest of the Paris Club.

But can WHO be empowered or strengthened as an agency with autonomy to set norms, ensure coordination and enforce compliance around a critical global public good – such as global public health and health security during a pandemic? This question is already on the agenda of the newly launched evaluation of WHO, as mentioned by Lee. It is also central to discussions within the WHO and its regional offices, as Vivian Lin illustrates with reference to an initiative in WPRO. Lin describes how the regional office rapidly organized itself to explore the urgent and real questions facing the organization as it moves into a still unknown future with or without COVID-19. This exercise addresses not only the health system and medical response, but also – as Lin and Mercado describe in greater detail – the role of non-pharmaceutical interventions and behavioural change which call for new ways of working with and through civil society organizations and communities. Thus, in the midst of a pandemic, we see innovation and collaboration at various scales and in different forms – within WHO’s regional offices (made possible by its particular institutional structure), as well as in other regional organizations (such as the AU) which are nurturing innovation and responsiveness to the needs of countries separate from the geopolitical battles taking place at the global level.

The focus on WHO as if it were only its Headquarters, and especially the criticisms that feed the dichotomous framing of WHO discussed above, misses much of this complexity. A GSP perspective is particularly valuable in identifying developments at different scales (subnational, national, regional, and global) and analysing how these interact with, or are ‘folded’ around, each other (Stubbs and Kaasch, 2014). The challenge in discussing global regulation is always that the appropriate institutions to realize regulation are for the most part found at national levels of government. Regional organizations may indeed have more scope for coordinating among countries on some issues, with more responsiveness to local contexts and languages, and potentially greater capacity to forge forms of solidarity that currently seem difficult to achieve at a global level.

What is the future for multilateralism in relation to global health? Proponents of multilateralism are of course dismayed at the US government’s decision to withdraw from the WHO. But they are also concerned about the lack of coordination at global and regional levels, the rise of nationalist or populist politics within countries and apparent competition among some governments to get access to protective gear and medications – including future vaccines. After all, major political and economic crises, such as the Second World War or the AIDS pandemic, brought governments, civil society organizations, researchers and philanthropists together to cope with common challenges. Wasn’t a global pandemic supposed to create similar waves of solidarity and collaborative efforts to minimize mortality, protect the vulnerable, and mitigate the devastating impacts on communities? Or perhaps COVID-19 has shown that it is easier to have ‘solidarity’ in a crisis response when the crisis affects someone else: if everyone is busy fighting the pandemic at home, who is left to help others? Could those who managed to get the pandemic under control earlier help others? What will it take to reorient the institutions – and possible/where necessary rebuild?

COVID-19 has come at a point of major disruption in the wider geopolitical and strategic context. China, as a relatively new player in the multilateral and development system, has been devising and adapting a global development strategy that combines bilateral cooperation with partners in the global south, along with more active multilateralism, participation in Bretton Woods institutions and new partnerships (such as GAVI), as well as through new mechanisms, such as its own Belt and Road Initiative and South-South Cooperation Assistance Fund, and the Beijing-based Asia Infrastructure Investment Bank (AIIB) and the BRICS bank. As Chorev points out, paradoxically just as China is playing a more significant role the US is stepping back – opening a path to a dramatic reshaping of the post-WW2 multilateral system. Alternative ‘horizontal’ development models, such as those advocated as part of South-South Collaboration, emphasize strategic alliances of mutual benefit and assert political autonomy in relation to the (neo)colonial global system but are they able to construct more socially inclusive development models that foster solidarity, equality and justice? Can these values flourish and shape the multilateral efforts to cope with complex crises such as those unleashed by Covid-19? Concern with China’s influence at WHO, and more broadly in multilateral agencies, needs to be analysed within the context of a larger set of global geopolitical rivalries. These rivalries go beyond the US-China contestation but involve confluence of many other trends such as growing dynamism in South-South Collaboration, and the steady efforts of actors such as Norway, Thailand, Brazil, and Japan to shape the global health agenda within the WHA.

In conclusion, from a GSP perspective, we can draw from the papers in this Forum a number of important suggestions in relation to the empowerment of the WHO. These include the potential for strengthening the global rights framework or normative values, amending the Constitution to clarify mechanisms of collaborating with non-state actors, introducing flexibility for organizational innovation and partnerships, and budgetary processes, and ensuring autonomy and powers of enforcement and enabling better coordination among WHO regions and other independent regional organizations. Rather than competing with public–private partnerships and initiatives, or relying on them for funding, WHO can be empowered to exercise its intended leadership role. None of these outcomes, however, will be easy in the current context. While it will be important to critically examine WHO’s response to COVID-19, the arguments being voiced in relation both to the United States’ decision to leave the WHO, and to WHO’s management of the pandemic, would appear to say more about the changing nature of multilateralism and politics at global and national levels, than about the WHO itself.