Comment - WHO's weakness is not technical, but due to lack of accountability.

Negin and Dhillon's proposal that functions presently carried out by WHO should be ‘outsourced’ to the Gates Foundation, the Gates-funded Institute for Health Metrics and Evaluation (IHME), Medicins Sans Frontieres and national drug regulatory agencies such as the US Food and Drug Administration (FDA), lacks evidence, relies on flawed logic and serves to obscure critical causes of WHO's failures, in particular the donor chokehold.

Negin and Dhillon cite a Cochrane review of outsourcing of healthcare in low-income and middle-income countries.1 Yet this review found only three studies that met its inclusion criteria all of which had a low quality of evidence and showed a high risk of bias.

WHO's accountability is currently to donors and governments. Outsourcing WHO's functions to Gates, IHME, the FDA and Mèdecins Sans Frontières (MSF) would further attenuate the accountability of WHO for the public's health.

Negin and Dhillon note that most current proposals for WHO reform have emphasised the need for greater funding from member states. ‘However, such a status quo solution may not match the magnitude of the problem and seems unlikely to actually resonate with funders who question WHO's efficacy’. This is a misleading account of the debate.

Most of WHO's disabilities are the consequence and not the cause of the donor chokehold. Donor dependence contributes to competition within WHO for the attention of donors which undermines collaboration across the organisation; programme oversight by donors weakens accountability through the management hierarchy; unpredictable and tightly earmarked funding precludes the development of a coherent and rational staffing structure.

The claim that the funders refuse to untie donor funds or increase assessed contributions because of concerns about efficacy is a smokescreen. The Director-General has repeatedly emphasised the need to untie tightly earmarked donor funds. The refusal of the donor nations to untie their voluntary contributions is directed to controlling the Organisation in the interests of the donors and their corporations.

Powerful TNCs and their nation state sponsors are particularly concerned about WHO's treaty making powers. Large transnational food producers are determined to forestall fiscal and regulatory approaches to sugar, fat and salt in addressing diet-related NCDs.2

The most fundamental weakness of WHO lies in its lack of accountability to the populations and communities whose health depends on WHO.3 WHO Watch,4 which is sponsored by the People's Health Movement (PHM) and other organisations, is directed to building the constituencies and networks which can hold WHO and its member states to account for their responsibility to protect and promote global health.

PHM argues5 that commentators who present WHO as merely a technical agency and who fail to consider the wider political economy of global health governance are effectively adding their support to those commercial and political interests who are determined to prevent WHO from doing its job.