COVID-19 Blog
04 May 2020

The World Health Organization as an Orchestra? Maybe, but not your Ordinary One

Over the last weeks, news outlets and social media have been flooded with headlines on the World Health Organization’s (WHO) role in the Covid-19 outbreak. People around the world are seeing various headlines, such as “The WHO is inefficient”, “WHO dodges questions about Taiwan”, or “US cuts funding to the WHO”, and may be getting swayed by what they read without fully understanding what is actually going on.

Until very recently, I was one of them. I was one of those who tried to inform myself on various issues happening in the world, but no matter how hard I tried, I could never fully grasp discussions related to the United Nations (UN) because they were so complex and distant.

Many articles tend to speak to a specific audience. They are usually too technical, using many undefined terminologies and acronyms. In other words, they are written in ways in which the readers are expected to have some basic knowledge of the issue at hand. But many people do not, and this becomes a problem when we live in times like these where the WHO is no longer an organization whose activities are the interests of a few pundits, but touches upon the lives of many around the world. Certain actors are purposefully exploiting this information gap for their own opportunistic motives. It is, therefore, up to people working in this field to tackle what the WHO has called an ‘infodemic’ by providing accessible information which explains what the WHO does and how it operates.

This piece attempts to illustrate the WHO’s basic functioning and what it can and cannot do for a wider public by comparing the WHO to something hopefully more relatable: an orchestra. But not just any orchestra … a high school orchestra (for reasons you will later see why). I am aware that I am not the first, and certainly not the last, to use the analogy of an orchestra to describe an organization – it is frequently used to analyze the functioning of international organizations and most currently in the context of Covid-19 and the WHO, particularly concerning WHO Director General Tedros’ leadership.

This piece, however, serves to provide the wider public with a more tangible understanding of the WHO and its work. Using the orchestra as a descriptive analogy, I hope to provide laypeople with the tools to better understand the developments at the WHO.

Meet the Orchestra – in a nutshell

Imagine a high school orchestra with 194 instruments from all over the world. Each instrument represents a country (also called a “Member State”), and the student playing the instrument is the government of that country. The students playing in the orchestra usually change every few years, but some stay longer than others – this depends on how the respective countries choose their leaders. It is important to differentiate the instrument from the student who plays it because the tune that comes out of the instrument is influenced by whoever holds it.

This orchestra was not established by the headteacher of the school, but by students who wanted to create an environment where they can come together to play music. This means this orchestra is a student-led body, and all decisions – such as the establishment of certain ground rules, selection of their conductor and choice of music to play for their next concerts – are made by the students and the students only.

When you hear that the WHO is ‘owned’ or ‘driven’ by its Member States, it means that decisions about its scope of activities and competences are up to the decisions of Member States. These decisions, amongst others, include, electing their conductor, the Director General (DG), every five years, deciding which health-related issues to tackle, and how to finance the organization.

As with many modern orchestras, this orchestra has a conductor – the WHO DG who will be introduced in the next section– and four sections: string, woodwind, brass and percussion. Now, all sections are equally important, but in our orchestra, the role of the string section – which, in many Westerns orchestras are considered the “heart” of the orchestra - is particularly important. Why? Because this is where some of the major contributors and players in WHO sit.

These include the G7 countries: Canada, France, Germany, Italy, Japan, the UK and the US. China also sits here, for reasons you will find out in just a moment. Whilst I would like to introduce you to all of our musicians and sections, for the purpose of this article, I would like to focus on two of them: the principal violinist and the second violinist.

The principal violinist, or concertmaster, is the US. A concertmaster has a number of responsibilities – they make decisions on bowing (how and when to pull the bow up/down) for their fellow string musicians, play the theme of a piece and the solos, and tune the orchestra before the rehearsals and concerts. They are crucial to the orchestra.

Although the other members of the string section do not blindly follow the US, it remains crucial for providing direction in the WHO, particularly as it is the single largest contributor. In short, the US possesses a strong position in the WHO and can support it in important ways, such as “supporting research work”.

The second violinist is China. Now, in case you are unaware, in the world of violinists, there is often times a competition between the concertmaster and the second violinist – there is this mentality that the concertmaster is superior to the second. The issue is a lot more nuanced than this, but let’s keep it simple for the sake of our discussion.

Although China has not been a large financial contributor to the WHO – contributing only 0.21% to WHO’s total annual budget for the biennium 2018-2019 – it has been increasing its position in global health over the years. For instance, China intends on building 100 health projects for women and children in developing countries. The Covid-19 outbreak, furthermore, revealed the world’s dependence on China for medical supplies, such as masks, test kits and protective gear.


The conductor – weak by choice?

Let me now introduce you to the conductor of our orchestra – the WHO’s Director General (DG). People usually see conductors on stage during concerts, waving their sticks around full of expression, indicating the correct entries for each member and setting the tempo of the music. Similarly, people see the WHO’s DG on the media mainly – if not, only – during disease outbreaks such as Ebola, Severe Acute Respiratory Syndrome (SARS), swine flu and currently, during Covid-19. But a conductor does a lot behind the scenes, one of them being, having the students pay attention during their practice sessions and do their fair share of work.

But, as in many high school organizations and teams, there are the diligent students and the slackers. Some students take the orchestra seriously and others don’t – this means some students pay attention and take practice seriously whereas others don’t. At the moment, our conductor can neither single out that one student who is fiddling on their cellphone nor reproach the students that have not done their homework because they don’t have the disciplinary tools available at their hands.

Particularly regarding practice, the moment the students leave the music room, it is up to each student to do their job, and the conductor has to trust that they will do their part for everyone else in the group. You must be asking yourselves why the conductor does not have the disciplinary tools. The answer is simple: the students don’t let the conductor have it. Remember, as we discussed earlier, this orchestra is owned and led by the students, and all decisions are taken by the students.

Similarly, the WHO DG currently does not have the tools to force Member States to do something and to hold them accountable for their (in)actions. The WHO is set up in a way that relies on the cooperation and goodwill of each Member State. If something goes wrong, the Member States have to work together and figure out a solution.

Going back to our orchestra, what can the conductor do to make the students pay attention if they have no disciplinary tools at their hand? For the moment, the conductor only has the power of persuasion to convince the students. And as every student responds differently, the conductor has to adapt their communication strategies – some take criticisms better than others, others need to be encouraged and cajoled into practicing.


Financing – keeping the orchestra running?

To keep the orchestra running, each student must pay an obligatory membership fee every year. This fee covers the cost of the music room, the maintenance, and gives students free access to the many practice rooms that are only accessible with a special card. But here’s the catch – not all students have to pay the same amount. The students in our orchestra come from diverse backgrounds. This means some students are wealthier than others. To make it fair, the orchestra is set up so that the wealthy pay more.

In addition to this membership fee, students can also pay a voluntary fee that covers the costs for the provision of class snacks, workshops, and food for the orchestra’s pet rabbit, Rabbit. Those who pay this fee can also specify for what activity they want their money to be spent on. Students don’t have to pay this fee but paying this gives them more say in any decisions the orchestra takes. For instance, if you contribute to Rabbit’s snack, you have more say in which snack to buy than someone who hasn’t paid for it.  

What I just described to you, in a nutshell, are the fees you keep on seeing and hearing about. The membership fee in WHO is called “Assessed Contributions (AC)”, calculated on the basis of a country’s population size and wealth. It is simply a membership fee that every member of the WHO has to pay to keep the organization functioning. The voluntary fee that is not aimed at anything specific is the “Core Voluntary Contribution (CVC)”, and the voluntary fee that is aimed at something specific is the “Specified Voluntary Contribution (SVC)”.

So, what exactly are these activities that the contributions go to? Besides tackling pandemics, the WHO does a lot of other things. Amongst others, it sets health standards and guidelines on vaccines and labels on drugs; fights infectious diseases such as HIV/AIDS, malaria and tuberculosis; promotes nutrition and exercise to fight obesity; works on improving the mental health of individuals; trains healthcare workers around the world; and the list goes on. Member States have the choice of paying the WHO and letting the organization allocate money to specific issues, or use the SVCs to pay for their “pet projects” (programmes different Member States have been investing in).

All of this sounds as if the WHO has their financing together, so why do we keep on hearing about them being broke and why is it such a big deal that the US froze their funding to WHO? In the past, the majority of WHO’s revenue came from ACs, but in the 1990s, Member States froze their annual membership fees, first in nominal and then in real terms. This means the WHO’s core budget does not grow anymore despite the increase in their activities.

As a result, the WHO has become increasingly dependent on CVCs and SVCs which remain unpredictable as you never know when Member States are going to change their minds. It also doesn’t help that Member States don’t necessarily pay their ACs on time and the WHO cannot enforce payment discipline (outstanding payments of each Member State).

To give you an idea of how skewed the contributions are, in the biennium 2018-2019, the ACs totaled USD 956.9 million (17% of revenue) and the voluntary contributions (both CVC and SVC) totaled 4.49 billion (80%). Imagine if the orchestra is unable to influence what to use their contributions for.  Students may fund projects which serve a certain purpose, but are not necessarily the most important needs of the orchestra – you can invest in Rabbit’s food, but that’s not a priority to keep the orchestra running. In short, using SVCs provides wealthy states with an opportunity to influence the WHO’s agenda according to their liking by funding certain programmes.¨


The Covid-19 Outbreak – a concert gone wrong

As I mentioned earlier, the WHO is active in various areas throughout the year but comes to the public’s attention mainly during health emergencies, and more specifically, pandemics. In our orchestra analogy, the end of the year concert where the whole school comes to see the students perform is the pandemic… yes, not the most joyous concert, but a rather grim one. Our orchestra is currently performing a piece entitled “The Covid-19” which is going exceptionally disastrous in the eyes of some – students are playing off-key, off-tempo, come in at the wrong time, and some do repeats in sections they had agreed to skip during rehearsals. To make things worse, the concertmaster messes up their solo and storms off stage. Students are blaming each other or are complaining about the conductor. In short, it is a mess. The concert is not even halfway through and the audience has good reasons to express various concerns. Let’s briefly look at two specific issues:

The DG’s leadership role – a conductor to blame?

When a high school concert goes bad, usually the first person blamed is the conductor – it is the fault of the conductor for not being able to control a group of teenagers. But as we have seen over the course of this article, the conductor has very little authority in this orchestra because all power lies in the hands of the students and they have no tools to discipline those who misbehave or fail to practice.

Remember we discussed about practice earlier and how the conductor can only give guidance? In the case of Covid-19, the “practice” refers to the recommended measures to tackle Covid-19. The WHO and Tedros can provide guidance on how Member States should address the outbreaks in their respective countries – such as conducting tests, tracing contacts and cancelling mass gatherings – but it is ultimately the decision of the leaders of the Member States to interpret and implement the measures. This is why you see different countries pursuing different quarantine policies. If you are unhappy with the way your government has been handling the disease, Tedros is not necessarily to blame but the leader of your country.

As the DG does not currently have the authority to impose measures on Member States, they have to use various approaches with governments to achieve cooperation. Imagine a conductor who publicly singles out one of their students for having misbehaved – the student may not cope well with the criticism and shut themselves off. Similarly, DGs need to adjust their proceedings with their Member States.

We see this playing out in the Covid-19 outbreak with Tedros being criticized for being “too nice to China”. Comparisons are drawn to Gro Harlem Brundland who held the DG position during the SARS outbreak in 2003. She is remembered for publicly shaming China and the city of Toronto for acting irresponsibly in controlling the outbreak. Though her action was not necessarily well received back then, some are calling upon Tedros to do the same right now with Covid-19.

Yet, Tedros’ approach, namely praising China instead of criticizing it, allowed the WHO to build a constructive working relationship: it ultimately led the WHO to gain access to China, allowing its technical team to gain a better understanding of the situation on the ground. In short, every DG, or conductor, needs to evaluate the situation and decide which course of action is most appropriate, bearing in mind their limited authority and enforcement tools.


What’s the orchestra going to do without the concertmaster?

As you may have already guessed, the concertmaster messing up their solo and storming off stage in the middle of the concert illustrates the US freezing their funding to the WHO in the middle of a pandemic. I should mention here that though this may be the first time the US froze their funding to the WHO, the US have threatened to leave the WHO in the past and have even been paying its dues in the last minute to pressure the organization. In addition, before the pandemic, Trump’s government seemingly had planned on reducing its contribution to the WHO in 2021 by half of its 2020 contribution, from USD 122 million to 58 million.

At the moment, no one knows for sure what the freezing of funding really means, or what the exact repercussions are. But one thing is for clear: a potential disengagement of the US from WHO will create a vacuum, which others may seek to fill. Remember at the beginning we mentioned the tension between the concertmaster and the second violinist? Well, now that the concertmaster is off stage, the second violinist is greedily looking at the empty seat next to it. But getting that spot is not going to be easy because they may not be trusted by the rest of the orchestra.

In an orchestra, when the concertmaster leaves, the assistant concertmaster usually takes over. In the case of the WHO, there is, however, no clear assistant concertmaster. At the moment, we see various countries pledging additional funds to the WHO in reaction to the US’ announcement, including Finland, Ireland and Saudi Arabia. China has also been one of those increasing its contribution to the WHO.

Whether these countries are merely trying to fill the financial gap left by the US or are eyeing a larger political role in WHO remains to be seen. It is, however, almost certain that an increased politicization and wrangling over the leadership in WHO will not lead to a more coherent approach. In other words, an orchestra characterized by a weak conductor and a disengaging concertmaster is unlikely to produce a fine tune. Additionally, reforming the orchestra and preparing it for the next concert is only possible if one remains a part of it, especially since there is no other orchestra to replace it.


So… what next?

Though the concert is not over, both the audience and the students themselves are realizing that there is a desperate need to change the way they function. At the moment, experts at the global level are talking about strengthening the WHO by giving it more legal and financial power. This means, giving the WHO and the DG the power to hold countries accountable for their in(actions), through, for instance naming and shaming, which at the moment does not exist.

It would be helpful for our conductor if the students gave them the ability to send those who misbehave to the principal’s office or have parents supervise their children at home during practice. Specifically for the global spread of diseases and other health risks, the WHO has the International Health Regulations (IHR) – it is a legally binding agreement that calls upon the Member States of the WHO to cooperate through, amongst others,  building capacities in their respective countries to detect, assess and report public health events. But again, the WHO does not have the tools to enforce the IHR upon its Member States. This is why experts at the global level call upon the urgent need to revise and strengthen the IHR.

At the same time, there is a need to ensure the WHO establishes a more stable funding system, one that relies less on one main funder, less on voluntary contributions and more on ACs, and has proper disciplinary measures to ensure Member States pay their dues on time. It needs to have a system that does not leave it scrambling for money when one donor leaves, and that does not affect the whole organization and its work.

But both decisions at the legal and financial front are up to the Member States – they must decide whether they want the WHO to wield more power or not. At the same time, it means that it is up to us to demand reforms to the WHO from our governments. Going back to our orchestra, maybe it is high time the parents tell their children to rethink the way their orchestra is organized so they can put in a better performance next time. But, as we all know, teenagers want a certain level of freedom and autonomy. Let’s see if they go that extra mile to get that authority imposed upon them.

Acknowledgment: The author would like to thank her aunt, a professional violinist, for advising on the technical aspects of the orchestra.

Disclaimer: This article is not comprehensive and omits a number of details. Certain aspects from both worlds, the WHO and orchestra, have been intentionally selected and simplified for the purpose of this article.


Written by @KuriharaFumi, Research and Project Officer at the Global Health Centre


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