Every World Health Organization (WHO) director general (DG) election centers around the call for "strong leadership." Now that member states have finalized their nominations for the next WHO leader, the global health community should consider the institution that the next DG will inherit, the reform process already underway, and whether they are prepared to be honest about what is broken and why.
Although the DG nomination process is following protocol, the WHO is not experiencing a normal leadership transition. As reported [PDF] to the World Health Assembly, WHO's global staffing will be reduced by a quarter in 2026, and the organization faces a substantial shortfall [PDF] in securing its full 2026–27 program budget. Given the staffing and funding reductions and the changing global health landscape, member states face a fundamental question over the role WHO should take in global health governance, which will define the organization for the next generation.
The global health community should consider the institution that the next DG will inherit, the reform process already underway, and whether they are prepared to be honest about what is broken and why
The global health community should approach that question the way countries are expected to approach a Joint External Evaluation, a collaborative process to assess a country's capacity to respond to health risks. For WHO, a similar serious and credible health security review should be a genuine reckoning with where the system has fallen short.
The dysfunction in the current global health architecture is not due to any single actor, nor can it be attributed to WHO. Member states, donors, and philanthropic institutions created a range of parallel initiatives and financing mechanisms because they judged WHO to be unable or unwilling to assume certain functions when they were needed. During the COVID-19 pandemic, those tendencies intensified, leading to a proliferation of new initiatives that were intended to get through the crisis instead of to improve the underlying architecture. Although these actions were in the pursuit of legitimate goals, they have resulted in a fragmented system beyond WHO's ability to coordinate—it is an architecture that WHO is expected to make coherent but neither controls nor finances.
At the seventy-ninth World Health Assembly, member states adopted a decision [PDF] establishing a joint process to support reform of the global health architecture. The official problem statement framing the process is notably self-critical, with WHO leadership and member states acknowledging that "the global health architecture has not kept pace" with country contexts, and that it is characterized by fragmentation, duplication, and misaligned priorities. If the joint process is to be the central vehicle for rethinking global health governance for the next decade, those leading reforms should be clear on the weaknesses in its process in addition to the architecture itself.
Subsidiarity and the Internal Federation of WHO
When WHO was established [PDF], the relationship between headquarters and its regional offices was a political compromise that created a single organization with semiautonomous regional bodies having their own governance and accountability lines. That structure has real advantages; it has given countries a greater say in regional decisions and has enabled innovation tailored to regional needs such as the Pan American Health Organization's Revolving Fund to pool vaccine procurement across the Americas.
At the same time, WHO's federated structure creates a structural tension. Regional offices are supervised by regional committees and also remain subject to the general authority of the DG. These dual lines of authority contribute to overlapping responsibilities, uneven implementation, significant costs and inefficiencies, and diffused accountability [PDF]. The joint process does not clearly address WHO's internal federation. It commits to subsidiarity—assigning responsibility to the lowest level capable of acting effectively—and calls for [PDF] clearer differentiation of functions and mandates across global, regional, and national levels, but it says little about how this should apply within WHO itself. Previous reform efforts have sidestepped these tensions [PDF] instead of resolving them.
Problems of internal coordination and accountability have surfaced in multiple responses, including the delayed escalation [PDF] of WHO's response to the 2013–16 West African Ebola outbreak, which was in part due to challenges reaching senior leaders and slow decision-making within the organization. Related issues of internal management and accountability were exposed by WHO's failure to prevent and respond to sexual exploitation and abuse during the 2018–20 Ebola response in the Democratic Republic of Congo. While reforms followed both of those crises, the distribution of authority and accountability remains unsettled.
Most recently, the WHO Health Emergencies Program's Independent Oversight and Advisory Committee found that the allocation of authority within the program has diverged from the model approved when it was established in 2016, citing [PDF] increasing delegations of authority to regional directors over decisions, human resources, and budgets in emergency operations. The committee recommended clarifying the respective authority of regional directors and the executive director of the Health Emergencies Program and raised the broader question of whether the original model should be reinstated or formally revised to take into account lessons learned.
A realistic reform agenda is unlikely to reopen the WHO constitution, nor is that necessary, but it should clearly define who decides what at which level, and how accountability and subsidiarity are meant to operate within the existing federation. The agenda should include which functions are led globally, which are delegated to regions, and how disagreements are resolved. A reform premised on subsidiarity is on shaky ground if it does not define how that principle applies inside WHO itself.
WHO's Framework for Engagement with Non-State Actors and Mandates
In addition to clarifying roles within WHO, the reform process should also treat WHO's Framework for Engagement with Non-State Actors (FENSA) not only as the compliance framework governing stakeholder engagement in the joint process but also as an object of review and potential reform. FENSA's guiding principles state that engagements with nonstate actors should advance public health and conform to WHO's constitutional mandate, while preserving member-state authority.
The joint process commits to conducting stakeholder consultation "in line with" FENSA, and to reviewing current governance and collaboration mechanisms. That review should examine whether FENSA still provides proportionate safeguards while enabling the engagement with nonstate actors that WHO needs to fulfill its mandate.
Negotiated in 2016, FENSA predates the rise of health tools and data platforms driven by artificial intelligence (AI) that are now increasingly used across global health, from medical diagnostics and decision support to disease surveillance. Modern health and analytic systems rely heavily on predictive models, cloud infrastructure, and databases controlled by networks of public and private actors. These relationships raise long-standing concerns about commercial influence along with newer questions involving data rights, algorithmic bias, transparency, cybersecurity, and accountability for harm. FENSA cannot answer these questions, but answering them will require WHO to engage in a collaborative way with the entities that develop and control these systems.
At the same time, the Pandemic Agreement anticipates long-term operational and contractual relationships between WHO, manufacturers, laboratory networks, and sequence databases. These treaty-structured relationships require examination of how FENSA should apply to long-term operational and contractual relationships, including how due diligence should be maintained over time; how technical and operational participation should be separated from influence over WHO policy and decision-making; and how transparency, accountability, and remedies for noncompliance should be handled.
If the joint process inherits FENSA without interrogating it, WHO risks relying on a partnership framework whose rules and implementation practices were not designed for these technological, data-intensive, and treaty-based relationships. Safeguards do not need to be weakened to ensure that FENSA is a fit-for-purpose risk-management framework that enables high-integrity, transparent, accountable collaboration with nonstate actors in a more complex technological and data ecosystem.
Similarly, the joint process is restricted from proposing revisions to organizational mandates or specific mergers or consolidations, even as it is tasked with developing options to better align mandates and capacities, strengthen decision-making and coherence, and align financing across the global health architecture. The reform process cannot itself rewrite the mandates of other institutions. However, the current process allows the identification of misaligned mandates but not recommendations on how they could change in response to create the coherence the process seeks to achieve.
The task force governing the joint process includes representatives of the largest funders and dominant actors in global health—Gavi, the Global Fund, the Coalition for Epidemic Preparedness Innovations (CEPI), Unitaid, the Pandemic Fund, UN entities, the World Bank, and the Africa Centres for Disease Control and Prevention (Africa CDC)—and its recommendations will be submitted to the governing bodies of WHO and those participating organizations. In practice, the task force could find that several organizations finance or support overlapping functions while responsibility for another critical function remains either unclear or underfunded. It could recommend clearer division of labor or better coordination, but it could not propose that the relevant governing bodies consider narrowing, expanding, or otherwise revising their mandates.
Allowing the process to identify where mandate changes may be warranted would not give it authority to make those changes, but it would give the participating institutions and their governing bodies a shared assessment and basis for considering them. Without this, the outcomes of the joint process may be limited to calls for more coordination even when the underlying problem may lie in the mandates themselves.
Pathogen Access and Benefit-Sharing Annex and WHO's Increasing Operational Role
In parallel with the joint process, WHO's Intergovernmental Working Group is negotiating the Pathogen Access and Benefit-Sharing (PABS) annex to the Pandemic Agreement; the two tracks are proceeding as if they are independent even though their institutional implications are in tension.
The joint process seeks to align mandates and capacities across global, regional, and national levels, and to ground the reform in subsidiarity and country ownership. By contrast, draft PABS proposals could bring portions of the surveillance and genomic data ecosystem within WHO's governance arrangements through a WHO coordinated laboratory network (WCLN) and WHO-recognized sequence databases. The global supply chain and logistics network's modalities remain to be negotiated, leaving open how far that operational role will extend.
On paper, the WCLN concept repackages WHO's role in coordinating pathogen-specific lab networks for surveillance, risk assessment, and capacity-building. In practice, once tied to the PABS annex's terms and conditions and WHO PABS contracts, current proposals could give WHO a substantially expanded operational and oversight role over laboratories, contracts, and data flows. WHO would serve as the institutional counterparty for PABS contracts; administer the PABS system; help develop and apply terms of reference for WCLN laboratories and WHO-recognized sequence databases; operate a global PABS tracking mechanism; and receive and act on allegations of noncompliance, including by suspending or revoking WHO recognition.
Conditioning WCLN participation and access to PABS materials on adherence to terms and conditions administered by WHO would create additional obligations for national public health laboratories and other institutions involved in health emergency response and research and development. Those obligations may not always align with national priorities, budgets, staffing, or risk tolerance, raising questions about how they fit with the joint process's commitments to subsidiarity, country ownership, and sovereignty. The core issue is not whether WHO should take on a more operational role in some circumstances; member states could reasonably decide that it should. The tension is that PABS is building toward an expanded operational role for WHO while the joint process is constrained from recommending mandate changes and does not clearly address how subsidiarity should work in practice, including within WHO.
Emergency Versus "Between Emergencies"
The hard question is how mechanisms like PABS function between emergencies in a funding-constrained environment. Member states could reasonably conclude that centralized allocation of medical countermeasures during a declared pandemic emergency is justified. The urgency of such a situation requires collective action by governments and global health actors as well as the private sector, and a centralized mechanism that could address the market and allocation failures that disadvantaged [PDF] many low- and middle-income countries during the COVID-19 pandemic. In some cases, time-bound and clearly scoped operational authorities can strengthen, instead of undermine, the legitimacy of WHO's coordinating role. That trade-off is coherent in a pandemic emergency context.
Between emergencies, some Pandemic Agreement mechanisms would remain operational, potentially giving WHO an ongoing oversight role over participating laboratories, sequence databases, and other functions yet to be negotiated or implemented. An expanded operational role for WHO and the joint process's effort to align existing mandates and functions are not obviously compatible, and there is no clear forum where member states are being asked to reconcile them.
The Choice Facing Member States and the Next Director General
Reconciling these issues is a governance decision for member states. By the time the next DG takes office, both the joint process and potentially the Pandemic Agreement's PABS annex may already be settled. The real question is whether member states are willing to create a more coherent division of labor: what WHO can realistically manage, what it should stop doing, and which functions should move to bodies with clearer mandates and greater accountability to affected populations. Otherwise, the next DG will inherit an institution with unresolved contradictions.
The joint process presents a real opportunity. Whether it becomes a real reckoning depends on whether the difficult questions are asked and answered—not only those the process was designed to answer, but also those it was not.
