Tedros Adhanom Ghebreyesus visited an Ebola treatment center in the Democratic Republic of the Congo on 9 March.

L. Mackenzie/World Health Organization

The planet’s premier health agency has announced drastic reforms. Critics say they aren’t drastic enough

In a speech last week, Tedros Adhanom Ghebreyesus recalled the posters about smallpox that he saw as a child in his hometown Asmara, in what is now Eritrea. “I remember hearing about an organization called the World Health Organization [WHO] that was ridding the world of this terrifying disease, one vaccination at a time,” he said. Much has changed since then. Smallpox was vanquished; Tedros, who’s Ethiopian, is the first African head of WHO; and in a series of reforms laid out in the same speech, he is trying to restore the storied organization to health.

The changes aim to bring more talent to WHO and improve coordination between its headquarters in Geneva, Switzerland, and six regional offices. But some observers say Tedros’s agenda doesn’t address long-standing problems, including a chronic shortage of money, little power over how to spend it, and the regional offices’ prickly independence. “The main problems of WHO are unsolved by this reform,” says Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University in Washington, D.C.

Founded in 1948 as a United Nations agency to promote public health, WHO is partly financed by 194 member states, but most of its $4 billion annual budget comes from donors, many of whom earmark their contributions for specific projects. Tedros became director-general in 2017, succeeding Margaret Chan, who was heavily criticized for her handling of the West African Ebola epidemic. In last week’s speech, Tedros recalled the lofty new goals WHO set last year: ensuring that by 2023 1 billion more people benefit from universal health coverage, 1 billion people are better protected from health emergencies, and 1 billion people enjoy better health. To achieve them, Tedros said, will require “changing the DNA of the organization.”

The structure of WHO’s head office will change with the creation of key new positions. Indian pediatrician Soumya Swaminathan has been named to the new post of chief scientist, tasked with making sure “WHO anticipates and stays on top of the latest scientific developments,” said Matshidiso Moeti, regional director of WHO’s Africa office in Brazzaville. (She mentioned a recently established panel on gene editing as one example.) A new division headed by Swaminathan will house a Department of Digital Health to work on guidelines for issues such as patient confidentiality and big data. A new assistant director-general will oversee the fight against antimicrobial resistances.

Assistant Director-General Bruce Aylward, who headed a “transformation team” that prepared the reform, says many changes are meant “to encourage the best and the brightest to think about WHO as a place where you spend your career.” Right now, he explains, “Most people who come into WHO spend a couple of years here, or they stay 4 years but without a properly structured career progression.” Staff will be evaluated every 2 months instead of twice a year, and a new career path will be opened for scientists who want to stay in technical areas instead of becoming managers. A new WHO Academy in Lyon, France, will train health professionals.

Staff at headquarters will also have to rotate to regional or country offices in the future, which Gostin says should make the organization more diverse and more flexible. “WHO staff have been too white, too old, and too comfortable living in Geneva,” he says. Jeremy Youde, a global health expert at Australian National University in Canberra, agrees that greater staff mobility is key because it “can help build greater competency and understanding of local conditions.”

Youde is cautiously optimistic about the changes. “Tedros came into the position at a time when WHO needed to rediscover its mission and reassert its value within the global community. These reform efforts are a tantalizing possibility for WHO to do that,” he wrote in an email. But Gostin says the changes amount to “a lot of bureaucratic restacking the deck.” WHO’s annual budget is smaller than that of many U.S. hospitals, he says, and donors tie the agency’s hands: “I don’t think any organization could thrive under those circumstances.” Then there is the independence of the regional offices, which dates back to WHO’s founding and is often described as its “birth defect.” “It’s hard to see whether WHO can be more efficient or work more harmoniously without addressing it,” Youde wrote.

But Aylward says the reform begins to change the dynamic by clearly dividing up competencies. In the past, an issue like food safety might be the responsibility of one division in Geneva and another in a regional office, or might not be addressed at all, he says. “So when you have a foodborne outbreak or problem it is not clear: Who is the lead? How do you coordinate across the levels?” Now, headquarters will focus on things like the research agenda and global partnerships while leaving day-to-day technical work to the regional offices.

There is a lot at stake both for the agency and for Tedros, who has a 5-year mandate. “I’m really curious to see whether these reforms can be his signature accomplishment (or failure, if they don’t work),” Youde wrote. “They could make or break Tedros’s tenure.”