There is considerable interest in reforming global health governance with a plethora of recent reform proposals from actors such as the Wellcome Trust and Health Architecture Reimagined (HEAR). Moreover, in the aftermath of Covid-19 there have been numerous recommendations issued from a wide variety of multilateral and non-governmental actors such as The Elders, the G20 High Level Independent Panel on Pandemic Preparedness and Response, and the Resilience Action Network International (RANI) among many others.
Much of this current global health reform debate hinges on expanding institutional authority—whether through new treaty instruments, enhanced emergency powers, or extending mandates for international organizations (including their own). However, the COVID-19 pandemic and its aftermath exposed a deeper problem: not just that global health institutions were unable to move beyond one-size-fits-all policies and to adapt to varying contexts and thus performed poorly in a crisis, but that they extended policy influence in a way that tested and laid bare clear ethical, legal, and accountability deficits in terms of policy inclusion, health equity, public health outcomes, and wider socioeconomic considerations. In the absence of accountability and further legitimating properties, expanding the authority of international organizations and global health initiatives, including the World Health Organization (WHO), risks accelerating current global health policy shortcomings, fragmentation and distrust rather than fostering needed cooperation.
This observation is central to the analysis of the International Health Reform Project (IHRP), an independent, multidisciplinary initiative involving public-health practitioners, academics, clinicians, economists, legal scholars, ethicists, and former international officials. The IHRP examined the WHO within its post-COVID global health governance ecosystem from ethical, public health, legal, and institutional perspectives. In doing so, the IHRP has synthesized its core findings in two reports sharing the title The Right to Health Sovereignty: A Policy Report synthesizing findings on ethics, legality, governance, and accountability in international health institutions; and a Technical Report, which presents findings on global public health needs, international health policy, the practice of the WHO, and its ability to meet the demands of the 21st century.
The current policy environment—marked by renewed WHO reform discussions, pandemic treaty negotiations, and high-level reviews—presents a rare opening. Reformers face a choice: rush to double down on expanding authority in the hope of better performance or pause to rebuild the foundations that make authority effective in the first place. Since authority without sufficient legitimacy is ultimately an untenable basis for effective governance, these insights should shape any serious global health policy reform conversations now underway.
The problem: authority without legitimacy
During the pandemic, the WHO and allied global health actors played a key role in influencing Covid-19 response policies worldwide. Either through direct guidance or through tacit and/or explicit approval of specific national policies, WHO influenced national emergency laws, movement restrictions, the adoption of public health and social measures (PHSMs), and the prioritization of interventions. Although WHO recommendations themselves are formally non-binding, the WHO often conveys considerable epistemic authority, which when coupled with the financial power of aligned conditionalities within development assistance programs and emergency grants (such as those of the World Bank, Gates Foundation, and International Monetary Fund), WHO recommendations can exert significant power in the form of influence and compliance, particularly in low resource settings. As such, it is often the case that deviations from these conditionalities can carry meaningful diplomatic and economic costs.
WHO’s influence was critical during Covid-19, often associated with responses outside articulated legal mandates, without agreed ethical constraints and inclusive policy dialogues that could enable the inherent trade-offs to be made clear to policymakers. Structured accountability mechanisms tied to outcomes were frequently absent. The result has been the compounding of a long-brewing legitimacy crisis in global health governance, namely, where institutions often exercise various forms of power without perceived legitimacy.
This legitimacy crisis is global, not regional or ideological. Public trust surveys indicate declining confidence in health institutions across economies and political systems, especially after Covid-19. States have responded variably—some pursuing reform from within, others stepping back or prioritizing bilateral engagements. If legitimacy is the problem, simply giving more authority to global institutions is certainly not the solution.
Six patterns that describe the fragility
IHRP’s analysis (presented in nearly 500 pages in the two reports) identifies seven recurring patterns brought to bear during the pandemic experience that point to structural fragilities in global health governance.
1. Expansion of influence beyond mandate
WHO’s advisory role blurred into perceived governance or justification for extraordinary national actions, often without explicit legal grounding or universally accepted evidentiary thresholds. This weakened credibility and degraded perceptions of shared governance, especially where guidance carried significant social or economic costs.
2. Inconsistent application of ethical principles
Key public health ethics norms—proportionality, least-restrictive means, and informed consent—were unevenly applied and seldom balanced as evidence shifted. Emergency framings often overshadowed ethical and procedural constraint and guidance, sowing confusion and resentment. Global public health principles of equity, global common goods, and multilateral cooperation were quickly eroded under the strain of influential vested interests, market logics, nationalism and scapegoating.
3. Rights rhetoric without legal discipline
Human rights language proliferated during COVID-19, but often without clear mechanisms for adjudicating competing rights or reversing policies where rights clearly conflicted. When rights lack legal discipline and procedural safeguards, and recognized processes for adjudication, they become politicized, undermining their protective intent.
4. Financing dynamics that shape priorities
WHO’s budget structure, dominated by earmarked voluntary contributions, skews priorities and reduces institutional autonomy and ability to make more objective recommendations. Even well-intentioned donors can inadvertently distort agenda-setting, complicating perceptions of independence and weakening legitimacy. Over reliance on private partners for financing and program implementation allows for an uneven agenda setting power, which often creates cycles of dependency instead of locally owned resiliency.
5. Accountability deficit
There is a general shortfall in robust accountability mechanisms at the WHO, whether that be in the ability to scrutinize the Executive Board, the Director-General, or to hold WHO and the actions of its staff to account (with only weak and secondary accountability possible through Member State actions in the World Health Assembly or outside pressure groups). Nevertheless, the accountability deficit is not isolated to the workings of the WHO, since formal accountability mechanisms in global health policy are often unidirectionally pointed downward at national ‘recipients’ and local implementors with little directed back upwards to international organizations and their proxies. This results in an architecture where global institutions can act with high levels of impunity and without the necessary legitimating practice of being obliged to account for their actions.
6. Perceived erosion of sovereignty accelerates disengagement
Constant attempts to impose ‘one-size-fits all’ responses across diverse contexts fuels backlash. Evidence from COVID-19 and prior crises suggests that states interpret perceived impositions as threats to decision-making autonomy, prompting bilateral alternatives and regional solutions. This perception becomes more acute as policies drift further away from local alignment. Moreover, there is a well-established evidence-base highlighting the necessity of ‘health sovereignty’ in the creation of effective and sustainable health systems (as stated in The Paris Declaration on Aid Effectiveness, The Lusaka Agenda, and the Accra Reset). Yet, cross-purposes often ensue where local and global actors pursue different incentives and needs.
7. Reform proposals that risk deepening fragmentation
Calls for expanded emergency powers or binding instruments without addressing the underlying legitimacy crisis in global health governance will simply compound mistrust, fragmentation, and sub-optimal health outcomes. As witnessed within the ongoing negotiations around the Pandemic Agreement, authority without legitimacy drives resistance and disillusionment, not meaningful cooperation.
Why legitimacy matters more than authority
The distinction between legitimacy and authority is not semantic. Authority without legitimacy invites non-compliance, fragmentation, and polarization, as civil society and populations withdraw trust from institutions perceived as unaccountable, captured, or ideologically driven.
Legitimacy, by contrast, rests on ethical clarity, deliberative processes, legal discipline, and multidirectional accountability—commitments that require mutual benefit and shared recognition built through intersubjective understanding (solidifying binding international organizations and state commitments alike). These conditions enable more engaged voluntary cooperation and self-lawgiving, without which global health governance cannot properly function.
Rethinking reform: principles before power
Based on these patterns, IHRP suggests a set of design principles for governance reform: boundary clarity through clearly defined mandates limited to genuinely international functions (global public goods, political facilitation, data standards and sharing, etc.); ethical constraints integrated as binding limits rather than rhetorical add-ons; legal discipline through explicit thresholds, evidence standards, and sunset provisions; accountability mechanisms that allow review of recommendations and consequences; financing reform to reduce earmarked distortions; and respect for individual and national health sovereignty, recognizing pluralism as a stabilizing and legitimizing feature of cooperation.
These principles are not anti-multilateralism: they are prerequisites for making international cooperation sustainable, transparent, resilient, and fair.
The need to seriously rethink global health business as usual
Global health governance does not fail just because institutions are weak: it fails when institutions exercise influence that outpaces the legitimacy that undergirds voluntary cooperation and ignores the least powerful of its beneficiaries. The success of any international organization should be measured by its ability to be less needed, as local authorities become more resilient, not merely from continued expansion, new buildings in Geneva, and more self-justified authority. If reform efforts ignore that distinction, they risk entrenching the very fragmentation and mistrust in global health governance they seek to overcome.
The conversation should begin not with new powers, but with principles that can rebuild legitimacy.
An important disclaimer and reflection about the state of global health inquiry
The research atmosphere in global health has become highly charged, with assumptions, projections, epithets, and innuendo becoming increasingly commonplace (from all sides of the political spectrum). These encounters often act as a substitute for dialogue, scientific inquiry, meaningful debate and knowledge creation. And in doing so, they reproduce the very anti-science they often purport to detest. This climate is further supercharged via instantaneous social media posting on every and any topic as well as click-bait journalism aimed to grab headlines. As a result, it has become increasingly necessary to preempt knee-jerk and often unsubstantiated claims in advance. This is the case with the IHRP.
The International Health Reform Project (IHRP) is an independent, multinational, multidisciplinary initiative comprising public health practitioners, academics, clinicians, economists, legal scholars, ethicists, and former international officials — many with extensive experience working in international organizations and low- and middle-income countries. The IHRP operates free from political direction and financial interference of any kind. The membership of the IHRP includes different cultural backgrounds, political views and methodological approaches, and members were chosen because of their differences and known disagreements. Hence, the IHRP did not comprise the usual suspects often seen within intergovernmental discussions about global health and WHO reform.
The Brownstone Institute provided limited administrative support to the IHRP. It exercises no editorial, analytical, or strategic influence over the IHRP’s research, findings, or policy positions. All conclusions published under the IHRP’s name are those of its members alone. Independence was a strict condition of the IHRP given the divergent views of its members.
Moreover, despite allusions to the contrary, IHRP has no affiliation, formal or informal, with UK politician Nigel Farage MP, nor any connection with the organisation Action on World Health. These are entirely separate entities.
Lastly, the IHRP panel represents diverse views and came to its conclusions after many hours of often intense deliberation and debate. The IHRP fully understands that global health governance and WHO reform are contentious topics and that there is a plethora of opinion. Yet, fundamental to the scientific method and knowledge creation is that ideas should be heard, openly debated, and held to account as fully as possible. In this regard the two reports making up the Right to Health Sovereignty have striven to be comprehensive and detailed. No other recent attempts are as comprehensive or as deep. Most prior debate has been based on op-eds, short research articles, and WHO self-assessments (see systematic review by Bump et al., 2022). In the spirit of dialogue and a commitment to improving global health, the IHRP encourages genuine engagement, disagreement and conversation, regardless of your starting position, in the hopes that we can collectively find better ways forward.