An event happens. Four different people tell four different versions of what happened. How do we figure out how to move forward?
This is a very rough plot summary of Akira Kurosawa’s 1950 masterpiece Rashomon, but it’s also a pretty accurate description of what is happening to the World Health Organization these days. There’s probably a generation of folks who know Kurosawa because he was name-checked in Rent, but the Japanese director also gives us a window for thinking about international politics.
The World Health Organization (WHO) has come under an immense amount of criticism over the past few years for its poor handling of the Ebola outbreak in West Africa. In the face of the problems, WHO pledged to do better going forward. It created an internal independent review body to offer suggestions for reforms, and a number of external review panels have offered their suggestions, too. Everyone agrees that WHO needs to do better. It needs to respond to disease outbreaks more quickly. It needs to show leadership. It needs to coordinate better within its own structures, with various parts of the United Nations, with member-states, and with non-governmental organizations.
There’s broad agreement about the need to change. It’s when we try to figure out how WHO should reform that we get into a Rashomon-like scenario.
Take one of the most recent reform initiatives. In mid-November, WHO Director-General Margaret Chan announced the creation of a new health-emergencies program to coordinate WHO’s responses to health crises. This new program will also create the Emerging Diseases Clinical Assessment and Response Network (EDCARN) to provide guidance on caring for the ill during outbreaks.
Yay! Success! All is taken care of, and this post ends here, right?
Of course not.
Creating new institutional structures is a dramatic undertaking, requiring a broad degree of buy-in and support from member-states. Large reforms like this are difficult to pull off in the best of circumstances.
WHO, unfortunately, is not in the best of circumstances. It is an organization struggling to reassert its legitimacy and value after falling short in one of its most prominent tests. We can talk about how WHO was almost set up to fail when combatting Ebola (and I’ll get to those in a moment), but public perceptions of the organization are far from rosy.
The biggest problem facing EDCARN (and other post-Ebola WHO reform measures) is financial. Even with relatively modest aims, creating an office like EDCARN needs money. EDCARN needs $485 million for the 2016-2017 fiscal year. At this point, it has received less than 60 percent of that amount. Other efforts from WHO to support strengthening domestic health systems have faced similar problems.
This is not a problem of excess cost. It’s a problem of reformers not being willing to put their money where their mouths are. It’s a problem of member-states telling different stories. Everyone agrees that there need to be changes, but they tell different tales about who should support these initiatives or how they should be paid for.
WHO is woefully underfunded, and the organization has very little control over its own budget. The vast majority of money comes from donors for specific purposes; WHO only has full autonomy to decide how to spend the funds it receives through assessed dues. As a result, WHO is largely doing the bidding of the wealthy states who provide voluntary contributions. In fact, member-states specifically rejected an effort to increase their assessed contributions—essentially tying WHO’s hands.
Why is this a problem? It means that every time WHO wants to do something new, it has to go, hat in hand, to member-states to ask for extra funds. That’s a not a strategy for reliable, consistent funding. It’s also incredibly unhelpful in the midst of an emergency. One of the problems that hampered WHO’s response to Ebola was that it had to spend time imploring the international community to give it the money it would need to implement a response in the first place. If an organization doesn’t have a large budget and has little control over its spending decisions, it can’t just shuffle money around when an emergency pops up.
To put this into nerdy international relations terms (is there any other kind?), WHO faces a dilemma rooted in the principal-agent problem. WHO is the agent of its member-states; it’s the body delegated with carrying out certain missions and programs on behalf of its members. The member-states are the principals; they are the ones telling WHO what to do. The problem here (and one that Kurosawa understood well) is that WHO is being told different things by its different member-states. When the signals from the principals are conflicting, it can paralyse the agent. It’s not that WHO doesn’t want to act; it’s that it’s prevented from acting.
Implementing global health programs takes material resources, and WHO doesn’t have the ability to raise those funds independently. If the international community wants WHO to do its job, then it needs to come to an agreement about how to move forward. It needs to get its story straight.