Lauren Paremoer
teaches in the Department of Political Studies at the University of Cape Town and is a member of the People’s Health Movement
Though some argue that the WHO has become increasingly irrelevant, it is still true that WHO norms and standards impact national level health priorities and budgets. A recent example of this includes the WHO’s recommendation in July 2025 to use injectable lenacapavir for HIV prevention. In the global south where HIV prevalence rates remain high, this matters greatly as their governments now have to consider the possibility of adding this drug to their national essential medicines lists in future. The WHO can also enhance the voice of global south states on the international stage and act to advance procedural and substantive equity in health cooperation. For example, recent changes to the International Health Regulations create a mechanism whereby States Parties can review the future implementation of the revised regulations, to ensure accountability, equity and solidarity are centred in responding to public health emergencies of international concern.
That said, many key WHO decisions are taken in Geneva and then “domesticated” by national health systems. Therefore, to exercise control over national health systems, civil society organisations must engage in WHO processes. In the context of the “power politics” that mark the current conjuncture, the WHO’s principles and processes still give public interest civil society organisations an opportunity to shape its work: member states have equal voting power, documentation from meetings and about organisational operations are publicly available, and the Secretariat takes instruction from its member states about the strategic direction and priorities of WHO’s. And it is these member states that civil society should ideally influence and hold accountable through elections, protest, agitation, advocacy, strategic litigation – and much more.
To be sure, the opportunities for participation of civil society organisations in WHO processes have been an issue for some time. Speaking time allocated to civil society at Executive Board and World Health Assembly meetings have reduced from 3 minutes to 1 minute or less over the years and comes at the end of debates when delegates have already committed to their positions. Though a WHO Civil Society Commission has been established, it has been criticised for not sufficiently facilitating direct engagement with member states – thereby limiting their impact on substantive decision-making. Nonetheless, when compared with other multilateral institutions that impact “health for all” – e.g. the International Monetary Fund, World Bank and World Trade Organisation – WHO does take some positive steps to democratise decision-making in global health governance.
What risks does WHO reform pose in narrowing space for civil society participation, and eroding democratic space as a result? In terms of indirect participation, one might argue that civil society organisations are represented by their governments. Therefore, if austerity and restructuring lead to even more use of outsourcing of work to private consultancies or public private partnerships – something that has been happening for some years already – the voice and authority of member states in WHO decision-making will be further eroded, and the technical expertise of longstanding international civil servants will be lost. The 600 jobs that will reportedly be cut at WHO’s Geneva headquarters suggests that the reduction in staff will certainly put pressure on the organisation to do the same amount of work with far fewer people, and one “quick-fix” might well be to rely on outsourcing of this kind.
Another “quick-fix” might be to prioritise work that has funding. This will privilege issues and regions where funding is easily secured, without reflecting the priorities of affected governments and their people. For example, over the past two years significant funding by the European Union and GAVI has been made available for developing vaccine manufacturing capabilities on the African continent. This work is important, but vaccines – once developed – need to be “delivered” to patients via trusted and functioning health systems. Unfortunately, the AFRO region has long indicated that, compared to other regions, it is receiving insufficient funding to implement much of the health systems strengthening work needed on the continent. This can be attributed to another longstanding dynamic: the failure by member states to pay assessed contributions that can sufficiently finance the WHO’s base budget. Though this is not a new problem, restructuring and austerity is likely to deepen the distorting effects of doing work that benefits from voluntary contributions (and reflect the priorities of public and private donors) and ignoring work that falls into “pockets of poverty”.
What can civil society do to push back against this? Here I take inspiration from a recent position paper by the People’s Health Movement (PHM) that argues that “Global health governance could begin to pivot to more progressive positions – if PHM and other civil society organizations are willing to build and sustain the local, national and global political movements to demand this of our governments.” Central to this is encouraging and supporting member states to step up their assessed contributions so that WHO can plan and act autonomously and resist the influence of public and private sector donors, consultants, or philanthrocapitalist foundations in influencing its agenda and staffing. For civil society organisations this means also focusing their energies on dismantling the structural factors that constrain our governments’ investment in “health for all” nationally and internationally: burdensome debt repayments, unfair tax regimes, illicit financial flows, political authoritarianism, commercialisation and financialisation of health care, and discrimination and stigmatisation against marginalised social groups. The public character of WHO as the directing and coordinating authority on international health can only be defended and advanced if its members – who are also public institutions – tackle these foundational social determinants of health equity.
Lauren Paremoer teaches in the Department of Political Studies at the University of Cape Town and is a member of the People’s Health Movement. She writes this in her personal capacity.
15 October 2025