A few days before Christmas, the Financial Times reported that the Trump transition team will pull the United States out of the World Health Organization (W.H.O.)—on day one. This is not the first time Trump has made this threat, and all indications are that he will make good on the promise. The U.S. withdrawal from W.H.O., while challenging, may also present an opportunity. Never let a crisis go to waste.
The Financial Times report about the U.S. withdrawal generated significant heat in social media. However, the actual level of threat (and the opportunity it offers) needs to be put into perspective. We can assume that the Director General, Dr Tedros Adhanom Ghebreyesus, started planning for the possibility of a U.S. withdrawal prior to the November presidential election. Once the result was known, W.H.O. would have looked at it’s options in earnest, and in 12 days time, W.H.O. will be able to respond positively and proactively. At least, this is the hope. And if the new Trump administration doesn’t withdraw, the plans can be quietly shelved.
A significant loss of funding will necessitate reform. Because a multilateral agency like W.H.O. is not a commercial entity it does not have the same singular focus: make money. U.N. Agencies simultaneously pursue diverse (sometimes unaligned) positive outcomes. The sustainable development goals are a hallmark of this tension: economic growth, sustainable cities and communities, responsible consumption, climate action,… save the planet. Thus, any reforms required by substantial changes in funding must navigate a complex web of member states’ competing priorities and interests. These complexities include balancing the divergent needs of countries that vary on economic, political, social, economic, demographic, and geographic profiles. There are, nonetheless, strategic lessons to be learned from past crises in large complex organisations. Know your core business (even if it is a portfolio of activities), focus on delivering that, do it efficiently.
A good place to start is by acknowledging that W.H.O. is not a bastion of lean and efficient administration. Even the most ardent defenders of W.H.O. are under no illusions that it is an organisation with structural problems. There are, for instance, critical thematic overlaps in the organisation’s activities. These overlaps occur between W.H.O. departments, and between W.H.O. and other multilateral agencies and international non-government organisations (INGOs). The overlaps create significant inefficiencies in the delivery of global health. Given the health threats we face, a less entrenched, more agile agency would benefit the world. And the U.S. withdrawal could provide that opportunity.
The U.S. provides about 20% of total revenue. As such, the Director General should not let the opportunity for reform afforded by the U.S. withdrawal go to waste. A budget black hole is a perfect reason for institutional reform. Something has to go, if you no longer have the money to do all the activities you were doing before. Some reform will be short, sharp and unpleasant—dictated by the exigencies of circumstance, and some can be more gradual. If the planning process has been done properly, as W.H.O. prepared for the Trump presidency, it should all be strategic.
Focus reform on staff numbers and practice, and programmatic inefficiencies and overlaps. Engage in a strategic redundancy exercise. Renegotiate Staff Association rules that protect poor work practices—W.H.O. staff are international civil servants, not recipients of sinecures. Identify core current business and core future business, and focus effort there. Leave other agencies and INGOs to look after non-core business. Regardless of the reform outcome, W.H.O. can use its substantial convening power to ensure that the coverage of key health areas is not lost but redistributed and shared—this will prevent fragmentation. The funding crisis should also be used as a clarion call for member state financial support and for member state support of the institutional reform process. The loss of U.S. funding is also a political opportunity to push back against member states adopting purely transactional relationships with W.H.O.. Draw a line in the sand. Send the message, “You will not bully us”, and any countries’ efforts to destroy global health will be resisted.
In 2011 U.N.E.S.C.O. faced a funding shortfall following the granting of full membership to Palestine. The organisation went through the strategic process of terminating or scaling back low priority programs. They trimmed administrative and operational activities to focus on key deliverable priorities. They sought to diversify funding.
There are risks associated with any institutional reform process. The risks, however, are most obviously associated with a voluntary reform process rather then one forced on the organisation by circumstance—hence, the notion of never letting a crisis go to waste. The biggest internal risk is the alienation of staff by changing long-standing employment practices. The risk is unsought (staff will understand that) and needs to be balanced against the even greater risk of sinking into a sea-of-debt by failing in a broad fiduciary duty to member states and beneficiaries. Staff reforms will require open and transparent engagement with the staff association, which can be enhanced by member states supporting affected nationals. The greatest external risk is a dilution of W.H.O.’s mission and the further fragmentation of global health efforts.
Reforms must be approached judiciously and collaboratively, ensuring that W.H.O.’s core mission and credibility as a global health leader are not compromised. Goodwill (not the U.S.’s) is on W.H.O.’s side. Historically, it has been a massive global good. Is it imperfect? Yes. Does it get things wrong? Sure. Can it be improved? Absolutely. The measure of W.H.O. is not in its failures but in its successes: the eradication of smallpox; the elevation of HIV/AIDS as a global problem; the African Programme for Onchocerciasis Control; the worldwide reduction of infant and child mortality; and the coordination role in the COVID-19 pandemic. None of these successes are W.H.O.’s alone, and that redounds to the ultimate value of the organisation. W.H.O. is the multilateral space that promotes global health. It is the only global health organisation empowered by 194 (err…193) member states to promote global public health, set international health standards, provide leadership on health matters, and coordinate international efforts to prevent and respond to health emergencies.
If the U.S. does withdraw, it is almost impossible to imagine that any alternative organisation could be proposed. A world health organisation by any other name would be similarly exposed to capricious withdrawal by a member state responsible for significant funding. The remaining member states need to double-down on their commitment and support a reform process, or risk a collapse in coordinated global health efforts.
While I am being so generous with my unsolicited advice, I also have a humble suggestion for the speech Dr Tedros should make if the Trump team make good on its promise to withdraw. I was “inspired” by the speech given by the U.K. Prime Minister (Hugh Grant) to the U.S. President (Billy Bob Thornton) in Love Actually.
The United States has been a cornerstone of global health efforts—a key partner since 1948. But let me be clear. The World Health Organization is not a convenience. Nor is it a platform for unilateral decisions and capricious withdrawal. It exists not for the benefit of any single nation but for the collective good of all nations—nations coming together to confront challenges that no country can solve alone.
We have eradicated smallpox. We have led the global fight against malaria and polio. We led the Safe Motherhood Initiative. These achievements are not ours alone but the result of countries uniting for the common good.
For any country to withdraw at this time, in this world of increasing threats, is to risk undoing decades of progress that have saved millions of lives and improved the lives of millions more.
A global partner who turns away in times of shared need is no longer acting as a partner, and while we have valued past support, we will not be bullied into abandoning our values and principles. To withdraw is to selfishly turn one’s back on a shared responsibility, risking decades of progress globally and within the United States.
Diseases and crises do not respect borders.
While the decision by the President will have the greatest impact on the most vulnerable, let me assure you: W.H.O. will remain steadfast in its mission to protect those who need us most. We exist to ensure health for all, especially the most marginalised, and we will not waiver in that responsibility. We have faced crises before, and in crisis lies opportunity. We will adapt, persevere, improve, and deliver life-saving support—not for our survival, but to safeguard the lives and well-being of the world’s most disadvantaged communities—including those communities in the United States.