Seventy-five years ago on Friday – World Health Day – the World Health Organization’s (WHO) founding constitution became the first document to formally recognize health as a human right. Three-quarters of a century later, a WHO battered by the COVID-19 pandemic is juggling how to adapt to new health threats with achieving its most basic mission: public health for all. 

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” reads the opening passage of the 1948 constitution, still in effect to this day. 

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

Nearly 80 million people died in the two world wars in the years leading up to the establishment of WHO. Many lives were lost not from bullets or mortar shells, but from famine and disease. 

The wars, like the COVID-19 pandemic, touched all corners of the world, creating a sense of shared destiny that led to the establishment of the United Nations and its agencies to safeguard the world from another global conflict.

“In the beginning [of the pandemic], the entire world faced the same uncertain threat — and same uncertain future. That feeling of shared fate was the reason the WHO was founded 75 years ago, as countries were rebuilding after the collective trauma of World War II,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “It’s why the authors of the WHO’s constitution affirmed both that health is a human right, and that the health of all people is fundamental to peace and security.”

Two decades later, the world agreed to the WHO’s International Health Regulations, a framework for cooperation on preparedness and response to health threats that has defined the landscape of international global health ever since. 

In 1978, in the mountains of present-day Kazakhstan, the world upped its health ambitions by ratifying the Alma-Ata declaration, whose slogan set a deadline for the end of the millennium for what remains the WHO’s key unfulfilled ambition: “Health for all”. 

The finish line is far out of sight despite decades of progress

The goal of universal health coverage remains as distant as ever, but remarkable progress has been made in the WHO’s lifetime. 

Life expectancy globally has increased from 46 to 73 years, with the biggest gains found in the world’s poorest countries. Smallpox, a scourge on humankind for thousands of years, has been eradicated. Polio is not far behind, with cases falling by 99.9% since the 1980s. 

While the HIV and TB epidemics stubbornly fight on, they are significantly diminished. HIV and TB diagnoses that once equalled a death sentence are now treatable. 

Maternal mortality has fallen by a third and child mortality has been cut in half. Significant progress has also been made against a series of neglected diseases like river blindness, sleeping sickness, leishmaniasis, and many others. 

“The WHO can’t claim sole credit for these successes – the very nature of what we do involves working with partners to support countries as they implement policies and programs that drive change,” Tedros said. “But it’s difficult to imagine the world would have seen the same improvements in health had the WHO not existed.” 

But for every problem solved, five more remain in their place.

Progress against TB and malaria has stalled. Noncommunicable diseases like cardiovascular disease, diabetes and cancers now account for 70% of all deaths globally. 

The efficacy of life-saving antimicrobials pioneered in the mid-1950s are under threat due to over-use and unregulated use in sectors like agriculture and pharmaceuticals. 

Climate change is ushering in a new era of health threats intertwined with pollution and natural disasters. Air pollution kills nearly seven million people every year.

Access to health services remains vastly unequal between and within countries. Since 2000, access to essential services has increased significantly, but at least half the world’s population still lacks access to one or more services like family planning, basic sanitation or access to a health worker. 

“Often this is because of where people live, their gender, their age, or who they are,” said Tedros. “They are people living in poverty, refugees and migrants, people with disabilities, unique minorities or other marginalized groups.”

WHO estimates the world will face a shortage of some 10 million health and care workers by 2030. The most serious shortages will be in the poorest countries as skilled workers migrate to higher paying jobs in rich nations.  

The number of people facing financial hardship due to out-of-pocket health expenses increased by a third to almost two billion people in 2017. 

COVID-19 – along with exposing deadly flaws in global pandemic response systems – disrupted health services and economies, further increasing the number of people unable to afford to treat their health needs.

“The world needs the WHO now more than ever,” Tedros said.

Paycheck to paycheck: expectations of WHO outgrow a stagnant budget

Few people outside global health circles realize that the WHO operates on a shoestring budget. The organization tasked with bringing about universal health coverage for all does not even have one dollar for each of the world’s eight billion people.

For 2023, its adjusted budget is just $7.5 billion. The world’s largest economy, the United States, contributed just $680,000 – approximately 0.00000292% of its GDP.

In contrast to its budget, expectations of the WHO have grown over the decades. It effectively operates as a second health ministry in many of the world’s most impoverished regions, financing primary-care clinics, quarterbacking emergency and routine vaccine programmes, and providing medical training and guidance to local health authorities and staff.

The increased frequency of natural disasters driven by climate change have also forced WHO to take on new responsibilities as an emergency responder, providing things like sanitation services, essential medical supplies and staff support in affected countries and difficult to reach regions like northwestern Syria. 

In the last year alone, WHO teams responded to over 70 global health emergencies, including the return of Ebola in Uganda, cholera outbreaks in over two dozen countries and the Mpox epidemic. 

WHO also had boots on the ground to meet health needs in the conflicts in Ethiopia, Syria, Ukraine, and Yemen, and sent aid and staff to assist people hit by the floods in Pakistan and severe droughts in the Sahel and Horn of Africa. 

And not all funding given to WHO is created equal. Over 80% of the organization’s budget consists of “voluntary contributions”, which donors designate to be spent on specific initiatives like fighting HIV or malaria. This leaves under a fifth of the WHO’s already miniscule budget to be spent flexibly on its core mission of supporting public health. 

This lack of agency in the WHO’s ability to direct funding has become increasingly acute due to the rise of influential private charities like the Bill & Melinda Gates foundation and Gavi, the vaccine alliance. Between them, they account for 15% of the WHO’s budget, all of which is earmarked for specific projects dictated by the charities.

The voluntary nature of these contributions also makes them unpredictable, creating serious budgeting challenges for some of the WHO’s most essential responsibilities.  

“Much of the WHO’s work doesn’t make headlines,” Tedros said. “We bring experts together to distill the best science into treatment guidelines on which many countries rely. We set global standards like the International Classification of Diseases. We name pharmaceutical substances, monitor disease patterns, and provide technical advice to more than 150 countries on strengthening their health systems.

“Much of it is unglamorous, painstaking, and slow-moving work,” he said. “But it makes a huge difference.”

The Pandemic Treaty: towards a new approach to global health 

The WHO’s next chapter is prearing the world for the next pandemic, with member states currently negotiating a pandemic accord that aims to address the many weaknesses exposed by COVID-19 – the most glaring being equitable access to medicines and vaccines.

Vaccine hoarding by wealthy nations during COVID-19 was a sharp reminder of an earlier epidemic of HIV, when poorer countries only got access to life-saving antiretroviral medication to a decade after wealthier countries.

The WHO has proposed that it gets 20% of “pandemic products” manufactured during the next pandemic – including medicine, vaccine and protective equipment. It will then allocate this to poorer countries. 

There are huge differences in opinion and approach amongst member states, with these negotiations being the biggest challenge facing the WHO in recent times.

However, Tedros remains optimistic that member states will choose the right way forward.

“The WHO belongs not to those of us who work for it, but to the nations and people of the world who created it 75 years ago, with a vision for a healthier, safer, fairer world,” Tedros said. “Our vision remains unchanged: The highest possible standard of health for all people.”

Image Credits: US Mission Geneva, WHO, WHO.