Is the UN broken, and can we fix it?

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7516.525 (Published 08 September 2005) Cite this as: BMJ 2005;331:525
  1. Kelley Lee, reader in global health (kelley.lee{at}lshtm.ac.uk)
  1. Centre on Global Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT

    No—and aggressive fixes may make things worse

    The world summit to be held at the United Nations' headquarters in New York next week is billed as the largest gathering of world leaders in history. More than 170 heads of state will attend to give statements, go to plenaries and interactive round-table meetings, and adopt a final document of decisions and recommendations. There will also be a special meeting on financing for development. All this in three days. If there is one thing the UN is good at, it is holding big meetings.

    The UN also excels at setting big challenges. The summit is described as “a once in a lifetime opportunity to take bold decisions on the areas of development, security, human rights, and reform of the UN.”1 The thinking may be that tackling these four areas together is necessary in a globalising world—and taking advantage of the attendance of so many world leaders spurs such ambition.

    In recent weeks there has been much talk of the need for the UN to reform. Given that this meeting marks the UN's 60th anniversary, it seems an appropriate time to reflect on reform. But the past six decades are littered with debates and ideas on this subject. It is a perennial issue, and the best scholarly and diplomatic brains have struggled with how to make this organisational behemoth work better.2 3

    The UN is a management consultant's worst nightmare. The main purposes of the UN are to maintain peace and security, and to foster international cooperation,4 but with more than 190 sovereign member states, the UN represents the ultimate exercise in herding cats. The focus of much of its work, therefore, is communication. The UN serves as the world's talking shop for issues ranging (in health) from AIDS to zoonosis.5 Discussions are conducted in many languages and documentation is available in six official languages. Unsurprisingly, progress can be slow and painstaking. For the uninitiated, the inevitable compromises seem to prevent decisiveness and real action.

    In large part, the UN is an organisational compromise. Its three main parts remain the General Assembly (all member states), Security Council (five permanent and 10 non-permanent members), and the Economic and Social Council (54 members). In addition, a proliferation of specialised agencies, funds, and programmes form the extended “UN family.” Balancing power within these bodies and sharing financial responsibility for their work are continuing challenges.

    The UN's work on health has focused on the World Health Organization (WHO). As the UN's specialised agency for health, WHO has developed a diverse portfolio of work in pursuit of its broad definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”6 But having such a wide range of activities has made internal cohesion a major issue.

    Like other parts of the UN, over the years WHO has dealt with a changing world populated by new players and new ideas. As well as facing its fair share of calls to reform, WHO has had to take account of other bodies, both within and outside the UN system, that are increasingly active and play crucial roles in global health. These bodies include non-governmental organisations, charitable foundations, and the private sector. Combined into new bodies such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and a plethora of other global public-private partnerships,7 such organisations represent the search for innovative forms of governance and pose a practical challenge for the UN.

    New approaches to health development have over-taken reforms, with greater attention to tackling issues across sectors on themes such as poverty and equity. This month, the UN will also host the Millennium+5 Summit to evaluate progress towards the millennium development goals adopted in 2000.8 Three of the eight goals, eight of 18 targets, and 18 of 48 indicators relate directly to health.9 10 Many governments, however, are not acting on their promises. Lack of resources remains the key hurdle, even with new commitments on aid and debt relief made at the G8 summit in July 2005. The world is on target to be disappointed once again.

    It is difficult to speak generally about UN reform, given the diverse organisations in the UN family and their varying performance. Until something goes wrong, much of what the UN does can be invisible. Its day to day activity—ensuring compatibility of global communication systems, coordinating international air traffic, and achieving consensus on scientific standards and nomenclature—rarely attracts public attention.

    With the UN's ever growing mandate, its supporters argue, the real problem is its lack of sufficient authority and resources to implement its policies and plans effectively. Furthermore, the UN is often a convenient scapegoat to divert attention from the failings of member states. Critics of the UN point to the usual suspects: lack of coordination, poor leadership, petty (and sometimes not so petty) corruption, bureaucratic tangles, and waste of resources.11

    Will this world summit result in substantive change? On the heels of the UN Reform Act of 2005 threatening to cut American contributions (currently 22% of the UN budget) if key reforms are not undertaken, the Bush administration has appointed longtime critic John Bolton as ambassador to the UN.12 Among the hundreds of revisions to the final document proposed by Bolton is the dropping of all references to the millennium development goals. This may serve to focus the mind. But using the stick without offering enough carrots may divide world opinion further, at a time when the challenges posed by globalisation require closer cooperation than ever before.


    • Competing interests None declared.


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