The World Health Organization: no game of thrones

Have you heard of the World Health Assembly? Do you have any idea of its purpose or any sense of its effectiveness? Even people who have attended the annual meeting of the 194 member states of the World Health Organization might struggle to answer the second of those questions. The arena at the Palais de Nations in Geneva, where the assembly is held, is designed for important decisions about international health, such as how to respond to the threat of Middle East respiratory syndrome coronavirus or the prioritisation of rapid diagnostic tests for malaria (doi:10.1136/bmj.g4123, doi:10.1136/bmj.g3846, doi:10.1136/bmj.g3730). Politicians, lobbyists, bureaucrats, technocrats, business people, and interpreters—mostly the rulers in the world of international health and a few of the ruled—gather to network, promote agendas, debate, and lunch in the hope of inching us closer to a healthier world. The World Health Assembly is Game of Thrones with smartphones for swords and no murders in the great hall.

Deaths may occur elsewhere, especially in poorer countries, because of the decisions taken here, although deaths are more likely to occur because not enough decisions are taken. The assembly has become a marketplace and a talking shop, confused in purpose between technical meeting and political gathering. Ilona Kickbusch and Mathias Bonk argue that health is a political choice and that the World Health Assembly is at heart a political, not a technical, meeting and that it should behave politically and act decisively to ensure that it has an impact (doi:10.1136/bmj.g4079). Herein lies the dilemma for WHO, which is more comfortable being a technical organisation and whose political forays can create bigger problems than they solve. This conflict in purpose helps explain the failure of the World Health Assembly to have an impact and might lead you to question WHO’s ability to transform the assembly in the way our editorialists recommend.

WHO is struggling in other ways. Its core budget has atrophied, explain Sridhar and colleagues (doi:10.1136/bmj.g3841), and the slack is being taken up by powerful stakeholders. The Bill and Melinda Gates Foundation and the US and UK governments were responsible for 80% of WHO’s total budget in 2013 but also seek control over how the funds are spent. A desire to interfere in disbursements is understandable: corruption in healthcare, for example, is a major concern for donors (doi:10.1136/bmj.g4184, doi:10.1136/bmj.g3169). But this interference undermines WHO’s role, and poorer countries then worry that WHO is an agent for rich nations with political agendas—the powers behind the throne of international health. Some commentators conclude that these failings question WHO’s very existence. Sridhar and colleagues instead argue that the solution is to fix WHO’s financial problems to ensure its independence and neutrality, as it is the only international agency that can tackle the threats to health security across the world.

Perhaps WHO is a victim of the rise of the medical-industrial complex, described in 1977 by Arnold Relman, then editor of the New England Journal of Medicine, to signify the intrusion of investor owned businesses in the health system (doi:10.1136/bmj.g4212). Problematic funding and ineffective governance are serious threats to any organisation. They are increasingly a life or death issue for WHO, and they require resolution. There should be no thrones. This is no game.