The need for WHO reform

The Ebola epidemic has drawn unprecedented attention to the WHO and its deficiencies.1–3 However, WHO's shortcomings are not limited to its mishandling of Ebola alone and extend more widely. Checchi et al4 highlight fundamental challenges in terms of structure, governance and prioritisation of political considerations. In addition, Laurie Garrett of the Council on Foreign Relations states that “WHO has struggled to remain credible, as its financial resources have shrunk, tensions have grown between its Geneva headquarters and its regional offices”.3 The size and scope of the WHO lead to considerable management challenges with a senior member of the Organization lamenting “I think it may be one of the most complex organizations that exists”.5 Others have noted that the organisation lacks the confidence of donors amidst continuing underperformance.6 In a number of recent reports and esteemed panels, including the Harvard-LSHTM Independent Panel on the Global Response to Ebola, the need for fundamental and extensive reform of the WHO has been made clear.1 ,5 ,7

The institutional failures of the WHO have serious consequences for global health as evidenced not only by shortcomings in the Ebola response but also in Sri Lanka in 2009, Haiti in 2010, South Sudan in 20134 and with regard to the MDR-TB response in Papua New Guinea at present.8 There is a need for clear global leadership, particularly when it comes to establishing global technical standards, addressing challenges that cross or transcend borders, and responding to health crises, such as the Ebola epidemic, that require the mobilisation of unique skill sets, capacities and resources.

The time is ripe for reconsidering how the global health architecture should be reshaped to allow for greater assurance of global health and to prevent future health crises and pandemics. Most current proposals have focused on the ways the WHO could be made more effective and particularly emphasised the need for greater funding from member states. However, such a status quo solution may not match the magnitude of the problem and seems unlikely to actually resonate with funders who question WHO's efficacy. Alternative options must be raised.

The changing global health landscape

When the WHO was established, there were few global health actors, making it the standard-bearer and the institution that convened the greatest minds and talent working on issues of health. Now, however, the field of global health is a complex, multiactor arena where “rival multilateral organizations have taken control over much of the global health action and agenda”.3 The Global Fund for AIDS, Tuberculosis and Malaria, the GAVI-Alliance, the Bill and Melinda Gates Foundation, the World Bank and a large number of other multilateral and bilateral agencies as well as prominent non-governmental organisations (NGOs) play a major role in technical and implementation aspects of global health.

Given the emergence of these additional global stakeholders and the realisation that the WHO is struggling to meet its mandate, a new solution is needed that focuses not only on what the WHO has to do to strengthen itself but also one that leverages the expertise that exists in the sector. The literature on principal-agent theory in the context of international organisations provides an avenue to explore.9–11 Specifically, the model of orchestration promoted by Abbott et al12 is one that suits the mandate and authority of WHO. Hanrieder13 states that “lacking the material capabilities to perform its technical functions on its own, WHO… draws on its formal authority and convening power to mobilize other international organizations and non-governmental associations for research, surveillance and technical assistance activities”.

Building on this model, WHO should aim to outsource a number of its functions to other global agencies that are already leading the way.14 This would allow the WHO to focus on a small number of core activities where it has comparative advantage and to coordinate or orchestrate the broader array of global health actors to take on other activities. The WHO never was and never intended to be an implementer of global health activities. The Constitution of the organisation emphasises coordination, collaboration with specialised agencies and other organisations, furnishing assistance, assisting in providing and promoting cooperation15—all of which resonate with the idea of WHO providing leadership but outsourcing key activities. Such implementation tasks should rightly remain with agencies whose mandate and expertise lie in implementation. Indeed, the model of WHO Collaborating Centers represents an existing model of outsourcing technical matters to experts around the world using the WHO imprimatur.

Outsourcing global health functions

Positioning WHO as a regulator, orchestrator and clearing house of expertise resonates well with its global reach and mandate but acknowledges its limitations. Indeed, on its current website, the WHO itself states that subcontracting is a very good model in complex environments:In addition, as new independent or autonomous actors come on stage, it becomes less easy to rely on hierarchical authority. This compels health actors to reconsider their relations. It is increasingly common for such relations to be based on contractual arrangements, which formalize agreements between actors, who accept mutually-binding commitments.16

Though the evidence is limited,17 contracting out of services has been shown to be a successful model in health systems undergoing transition. Afghanistan18 ,19 and Cambodia's20 health systems have been strengthened by relying on regulated subcontracts between government and partners who have demonstrated expertise in district-level service delivery. This has demonstrated positive effectiveness and improved equity. While undoubtedly the scope of WHO's activities and global reach is much larger than that of a particular country, the subcontracting model has resonance and viability.

This model challenges WHO's current way of functioning in which it has tried to position itself as the leading agency across a huge range of global health activities. Such a model would require WHO to review each activity and each department from first principles: is WHO performing those roles well? is WHO performing those roles in a cost-effective manner? who else is conducting those activities and how well are they performing?

The subcontracting would likely be based on a financial arrangement, but some organisations might only seek the global imprimatur acknowledging them as the world-leading agency responsible for a certain activity. Such recognition might increase their own fundraising and credibility. Other organisations might seek funding—which, in most cases, would be cheaper for WHO than trying to either build up or maintain its own (less effective) competing department.

There are a number of examples of outsourcing opportunities open to WHO—especially in the technical and standard setting areas. The Gates-funded Institute for Health Metrics and Evaluation at the University of Washington is already the widely accepted world leader in global health data having led the Global Burden of Disease study. While the WHO's Department of Health Statistics and Informatics conducts a broader range of data collection and there is disagreement between the two bodies on some points,21 does the world really need two large organisations that conduct similar global studies?

The HIV response is another area where WHO's work has potential overlap with the work performed by other agencies. The WHO lists 23 of its departments being involved in aspects of the HIV response,22 while a stand-alone cross-UN agency—UNAIDS—already exists and is supplemented by the Global Fund, considerable funding by the Gates Foundation as well as large numbers of NGOs and university technical groups. WHO could more actively accede its HIV-related activities to UNAIDS and similar world-leading agencies.

The WHO conducts prequalification regulatory assessment of pharmaceuticals and related products including diagnostic tests in order to ease the burden on low-income country regulatory bodies. This is a useful process, but given poor review times and the use of a limited set of reviewers, wouldn't outsourcing this activity to a well-functioning low- and middle-income country or high-income registration body reduce duplication while supporting the strengthening of in-country systems (as well as providing that country with a revenue source)?23 ,24

In addition, amidst the fallout from the Ebola crisis, there have been calls for the WHO to compile a quickly deployable international medical corps to respond to humanitarian crises. Why does this role fall to WHO when organisations such as Médecins Sans Frontières and the International Rescue Committee already have committed experts willing to travel to crisis zones and systems in place to quickly mobilise a response. These organisations have the credibility, track record and networks to fulfil this role and could further be reinforced instead of trying to create parallel mechanisms within WHO.

Transitioning to an outsourcing approach

A process would need to be set up within WHO to manage this outsourcing model. A project management unit with high-level representation would need to assess each function of the Organization to determine whether it is appropriate to consider subcontracting that task. The unit would independently assess the cost-effectiveness and quality of that department or function within WHO and also determine whether expert-level skills might exist externally within NGOs, academia, bilateral or multilateral agencies.

WHO could then outsource activities to organisations or to consortia around key technical and functional areas of work for which such an approach might be suitable. WHO's role would be to curate and structure the tasks. Any outputs—whether standards or policy guidance—would be made available under a WHO imprimatur. This keeps oversight in the hands of WHO—preserving their global leadership and role in setting policy direction.

There are considerable challenges inherent in this transformative model. Contracting and regulation would clearly be important and challenging tasks. Successful management of contractors has real challenges that have warranted the development of a considerable literature in the fields of management25 ,26 and in principal-agent theory9 ,10 highlighting the importance of incentives and ensuring accountability, monitoring, communication and collaboration. Member states would need to support WHO in ensuring accountability. In addition, the WHO would have to improve the speed and responsiveness of its contracting services.

Such a system would require other agencies to take on greater responsibility in global health leadership. While some would be more than willing to do so, others have expressed reluctance. Joanne Liu, President of Médecins sans Frontières, has previously stated that her organisation cannot become ‘the world's doctor’ and needed to protect itself from being spread too thin.27 Liu supports WHO's leadership but acknowledges that the organisation “lacks the capacity and expertise to respond to epidemics”—a reality that this model can potentially overcome.28

Additionally, WHO might be concerned that such outsourcing would weaken the organisation's authority. But if the alternative is continued underfunding and undermining (as evidenced by the US CDC bypassing WHO and setting up an African Centres for Disease Control with the African Union29 and by the Secretary-General setting up UNMEER to acknowledge WHO's failure in the Ebola response30), then that is clearly a greater threat to WHO's presumed leadership. And using language around orchestration would allow the model to more explicitly maintain WHO's leadership position in global health.

The biggest challenge to reform in this (or any other) direction is organisation's existing governance arrangements made up of 194 member states.30 Convincing such a diverse group of the need for and direction of change is an immense task. This model does, however, provide some strong arguments that might resonate with member states: improved efficiency and cost savings; improved effectiveness by using the comparative advantage of other actors; and, most importantly, the realisation that the alternative might be the organisation becomes less relevant in the minds of donors and stakeholders.

Given the existing risk, a status quo model for the WHO coupled with impassioned pleading for more money will not convince donors nor will it lead to a reformed era of global health collaboration. This outsourcing model would allow WHO to be smaller, more dynamic and to use its resources where it can most make a catalytic difference—which would ultimately expand its leadership role and improve its standing as the custodian of health worldwide.