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Time to outsource key tasks of WHO to better-placed and capable agencies, say experts

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For decades, failures by the WHO to respond to global health crises have drawn criticism and calls for reform by policy experts, governments and independent financial donors from across the world that contribute three-quarters of its $4 billion annual budget.

Serious recent failures that have drawn fire include shortcomings in its response to the Ebola pandemic, health crises in Sri Lanka in 2009, Haiti in 2010, South Sudan in 2013 and its current response to drug-resistant Tuberculosis in Papua New Guinea.

"An outsourcing approach would allow WHO to maintain global leadership and oversight but would utilise external expertise more appropriately," say authors Associate Professor Joel Negin at the University of Sydney and Dr Ranu Dhillon from Harvard University.

"This would allow the WHO to be leaner and more focused, and would increase the contribution of other actors. We believe such reform is essential to the future of the WHO and of global health action."

Most current proposals to reform the WHO focus on ways it could be made more effective and attract more funding. But Negin and Dhillon say more financial muscle and incremental reforms will no longer meet the challenges of preventing, predicting and responding to today's globalising health crises.

"When the WHO was established, there were few global health actors," says Professor Negin, who heads the university's School of Public Health.

"Its unique positon meant it could bring the world's best minds and skills to bear on global health issues. Today, global health issues occur in a complex, multi-actor arena where rival multilateral organisations have taken control over much of the global health action and agenda.

"Given the emergence of new global stakeholders and the realisation that the WHO is struggling to meet its mandate, we need solutions that focuses not only on what the WHO should do to strengthen itself but one that leverages the expertise that exists in the sector."

Negin's co-author, Ranu Dhillon says the WHO should "outsource a number of its functions to other global agencies that are already leading the way. This would allow it to focus on a small number of core activities where it has comparative advantage and to coordinate or orchestrate the broader array of global health actors to take on other activities."

Negin and Dhillon say current WHO-functions that should be outsourced include technical matters such as research and surveillance, and on-the-ground responses to health issues and crises.

"The WHO never was and never intended to be an implementer of global health activities," says Negin.

"In fact, its Constitution emphasises that its principal functions are co-ordination, collaboration with specialised agencies, providing assistance, and promoting co-operation – all of which resonate with the idea of WHO providing leadership but outsourcing key activities.

"Re-positioning it as a regulator, orchestrator and clearing house of expertise would dovetail with its global reach and mandate but acknowledges its limitations."

Indeed, the WHO itself states on its website that subcontracting is a good model in complex environments: "In addition, as new independent or autonomous actors come on stage, it becomes less easy to rely on hierarchical authority. This compels health actors to reconsider their relations. It is increasingly common for such relations to be based on contractual arrangements, which formalize agreements between actors, who accept mutually-binding commitments."

Though evidence is limited, the authors say outsourcing has been shown to be a successful model in health systems that are in transition, especially in post-conflict or fragile states.

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