The World Health Organization was born as a normative agency: Seventy-five years of global health law under WHO governance

Abstract

The World Health Organization (WHO) was born as a normative agency and has looked to global health law to structure collective action to realize global health with justice. Framed by its constitutional authority to act as the directing and coordinating authority on international health, WHO has long been seen as the central actor in the development and implementation of global health law. However, WHO has faced challenges in advancing law to prevent disease and promote health over the past 75 years, with global health law constrained by new health actors, shifting normative frameworks, and soft law diplomacy. These challenges were exacerbated amid the COVID-19 pandemic, as states neglected international legal commitments in national health responses. Yet, global health law reforms are now underway to strengthen WHO governance, signaling a return to lawmaking for global health. Looking back on WHO’s 75th anniversary, this article examines the central importance of global health law under WHO governance, reviewing the past successes, missed opportunities, and future hopes for WHO. For WHO to meet its constitutional authority to become the normative agency it was born to be, we offer five proposals to reestablish a WHO fit for purpose: normative instruments, equity and human rights mainstreaming, sustainable financing, One Health, and good governance. Drawing from past struggles, these reforms will require further efforts to revitalize hard law authorities in global health, strengthen WHO leadership across the global governance landscape, uphold equity and rights at the center of global health law, and expand negotiations in global health diplomacy.

Full text

REVIEW
The World Health Organization was born as a
normative agency: Seventy-five years of global
health law under WHO governance
Lawrence O. Gostin
1
*, Benjamin Mason MeierID
2
, Safura Abdool Karim
3
, Judith Bueno de
Mesquita
4
, Gian Luca Burci
5
, Danwood Chirwa
6
, Alexandra Finch
1
, Eric A. Friedman
1
,
Roojin Habibi
7
, Sam Halabi
1
, Tsung-Ling Lee
8
, Brigit ToebesID
9
, Pedro VillarrealID
10
1O’Neill Institute for National & Global Health Law, Georgetown Law School, Washington, District of
Columbia, United States of America, 2Gillings School of Global Public Health, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina, United States of America, 3Berman Institute of Bioethics, Johns
Hopkins University, Baltimore, Maryland, United States of America, 4Human Rights Centre, Essex Law
School, Colchester, United Kingdom, 5Global Health Centre, Graduate Institute of International and
Development Studies, Geneva, Switzerland, 6Faculty of Law, University of Cape Town, Cape Town, South
Africa, 7Faculty of Law, University of Ottawa, Ottawa, Canada, 8Graduate Institute of Health and
Biotechnology Law, Taipei Medical University, Taipei, Taiwan, 9Faculty of Law, University of Groningen,
Groningen, The Netherlands, 10 Max Planck Institute for Comparative Public Law and International Law,
Heidelberg, Germany
*gostin@georgetown.edu
Abstract
The World Health Organization (WHO) was born as a normative agency and has looked to
global health law to structure collective action to realize global health with justice. Framed
by its constitutional authority to act as the directing and coordinating authority on interna-
tional health, WHO has long been seen as the central actor in the development and imple-
mentation of global health law. However, WHO has faced challenges in advancing law to
prevent disease and promote health over the past 75 years, with global health law con-
strained by new health actors, shifting normative frameworks, and soft law diplomacy.
These challenges were exacerbated amid the COVID-19 pandemic, as states neglected
international legal commitments in national health responses. Yet, global health law reforms
are now underway to strengthen WHO governance, signaling a return to lawmaking for
global health. Looking back on WHO’s 75
th
anniversary, this article examines the central
importance of global health law under WHO governance, reviewing the past successes,
missed opportunities, and future hopes for WHO. For WHO to meet its constitutional author-
ity to become the normative agency it was born to be, we offer five proposals to reestablish
a WHO fit for purpose: normative instruments, equity and human rights mainstreaming, sus-
tainable financing, One Health, and good governance. Drawing from past struggles, these
reforms will require further efforts to revitalize hard law authorities in global health,
strengthen WHO leadership across the global governance landscape, uphold equity and
rights at the center of global health law, and expand negotiations in global health diplomacy.
PLOS GLOBAL PUBLIC HEALTH
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OPEN ACCESS
Citation: Gostin LO, Meier BM, Abdool Karim S,
Bueno de Mesquita J, Burci GL, Chirwa D, et al.
(2024) The World Health Organization was born as
a normative agency: Seventy-five years of global
health law under WHO governance. PLOS Glob
Public Health 4(4): e0002928. https://doi.org/
10.1371/journal.pgph.0002928
Editor: Srikanth Kondreddy, University of Ottawa,
CANADA
Published: April 11, 2024
Copyright: ©2024 Gostin et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.

The World Health Organization (WHO) was born as a normative agency with unrivaled con-
stitutional authority to negotiate and adopt international legal instruments to advance global
health governance. Yet, it has adopted only two major legally binding instruments in its his-
tory—the International Health Regulations (IHR) and the Framework Convention on
Tobacco Control (FCTC). In the wake of the COVID-19 pandemic, WHO is embarking on a
fundamental reform of the IHR and is negotiating a new Pandemic Agreement. As the Organi-
zation looks back on the past 75 years and looks ahead to meet rising health challenges, WHO
must harness its legal authorities to shape global health rules and norms and facilitate account-
ability for them–strengthening global health law to become the normative agency it was meant
to be.
Applying public international law to address global health challenges, global health law
looks beyond the legal efforts of individual nations to encompass the larger set of determinants
that structure public health in a globalizing world. Global health law encompasses both bind-
ing “hard” law treaties and non-binding “soft” law instruments that shape norms, processes,
and institutions to realize the highest attainable standard of physical and mental health. WHO
holds expansive normative authorities to develop global health law instruments, including
conventions, agreements, regulations, recommendations, standards, and nomenclatures. As
contrasted with the agency’s technical or operational functions, these international legal
instruments provide a powerful tool to meet major global health challenges that no country
could address on its own. Recognizing that all nations face interconnected public health
threats, global health law can foster collective action to realize global health with justice under
WHO governance.
However, WHO has faced legal challenges throughout its 75-year history, revealing the lim-
its of global health law as a foundation of global health governance. WHO has long been chal-
lenged by state assertions of national sovereignty, with member states often reluctant to
establish binding obligations and at times failing to abide by existing obligations. During the
COVID-19 pandemic, WHO confronted unprecedented legal challenges, with states neglect-
ing international legal commitments in the pursuit of nationalist health responses. These con-
straints on WHO governance undermined global solidarity, leading member states to initiate
sweeping law reforms to meet future health threats.
Where WHO leadership has been shaped by global health law, law reforms under WHO’s
normative authorities will be essential to strengthen WHO governance. Given the limitations
of global health law–in the COVID-19 response and beyond–it will be crucial for law reforms
to take account of lessons learned from past challenges to ensure that WHO is prepared for
future threats. This review examines the central importance of global health law under WHO
governance, providing necessary understanding of the past successes, missed opportunities,
and future hopes of legal authorities for global health.
Legal authorities for global health
The normative foundations of the modern field of global health law were established by the
WHO Constitution [1]. Declaring “the highest attainable standard of health” to be “one of the
fundamental rights of every human being,” the WHO Constitution endowed WHO with a
range of normative authorities to “act as the directing and coordinating authority on interna-
tional health work” [2]. Upon its establishment in 1948, WHO set out to realize its interna-
tional health mandate through global health law–leveraging its constitutional authorities to
develop binding international legal agreements [3]. Yet despite its far-reaching lawmaking
powers under the WHO Constitution, WHO has largely sought to advance global health
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governance through technical guidance, country support, and soft law policies, limiting
accountability for international action [4].
The WHO Constitution grants WHO expansive international legal authorities to adopt
international conventions, regulations, and non-binding recommendations to address matters
of public health importance [5].
Establishing hard law authorities, Article 19 empowers the World Health Assembly to
“adopt conventions or agreements” with respect to any matter within WHO’s competence.
However, in its 75-year history, the Organization has adopted only one binding treaty–the
FCTC. In addition to treaty powers, Article 21 empowers the Assembly to adopt binding regu-
lations in enumerated areas of global health (international spread of disease, public health
nomenclature, diagnostic procedures, and international trade of biological and pharmaceutical
products). Under Article 22, these regulations are automatically binding on WHO member
states unless a state explicitly opts out. Building from the long evolution of International Sani-
tary Conventions, first adopted in 19
th
Century, WHO member states rapidly extended this
normative authority to develop binding regulations through the adoption of the 1951 Interna-
tional Sanitary Regulations, which would be renamed in 1969 as the IHR, governing interna-
tional action “to prevent, protect against, control and provide a public health response to the
international spread of disease” [6].
Beyond hard law, WHO has turned to a wide range of soft law instruments, including reso-
lutions, guidelines, action plans, global strategies, codes of practice, declarations, and recom-
mendations. While these instruments do not codify binding obligations under international
law, soft law can nonetheless be normatively authoritative [7]. Article 23 of the WHO Consti-
tution empowers the Assembly to adopt nonbinding recommendations, which have estab-
lished important global health norms, including on the marketing of breast-milk substitutes,
the sharing of novel influenza viruses, and the recruitment of health care workers. Outside of
formal recommendations adopted by member states, the WHO Secretariat has deployed an
expanding series of soft law instruments to harmonize national health policies (Fig 1). These
nonbinding instruments have addressed pressing health issues as broad as unhealthy diets,
Fig 1. Select hard and soft law instruments under WHO governance.
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climate change, and digital health. The flexibility of soft law has allowed WHO to deploy these
instruments rapidly and frequently to provide normative clarification of treaty obligations,
offer technical guidance on health matters, set health standards for national governments and
non-state actors, and ensure international accountability across an expanding global health
landscape [8].
New actors in an expanding global health landscape
The establishment of the United Nations (UN) system after World War II provided the mod-
ern international legal foundation for global public health under WHO, as states looked to
WHO to lead international legal advancements at the forefront of global health governance. As
the principal UN specialized agency for health, WHO inherited from predecessor organiza-
tions the legal responsibility for multilateral cooperation to control the international spread of
disease [9]. Yet, with its constitutional mandate to act as the “directing and coordinating
authority” on all international health work, WHO would have far broader normative authority
for international health lawmaking [10]. In coordinating the global community to address
common health threats, WHO was central to global health governance under the UN, binding
states together through international law to prevent disease and promote health (Fig 2).
However, amid political and economic shifts—from Cold War divisions to neoliberal eco-
nomic challenges—WHO struggled to maintain its institutional leadership and normative
influence [11]. The Cold War divided international relations into two opposing ideological
camps—pitting Western capitalist democracies against Soviet communist regimes—with these
geopolitical divides limiting WHO leadership to develop legal instruments [12]. Mounting ten-
sions between the Soviet bloc and Western states rapidly undermined the solidarity needed
Fig 2. UN secretary-general Trygve lie and WHO director-general brock Chisholm formalize WHO becoming a
UN specialized agency (Paris, November 1948). Republished from the World Health Organization under a CC BY
license, with permission from the World Health Organization.
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within the World Health Assembly to develop hard and soft norms in global health–with
Soviet states seeking to withdraw from WHO entirely for several years in the early 1950s [13].
Amid these geopolitical tensions, WHO avoided lawmaking initiatives at the height of the
Cold War, with contemporaneous legal scholars noting that WHO had “regarded it a prudent
tactic to rely less on regulations and more on the authority of international biomedical consen-
sus,” recognizing that this “may not in all instances be as effective as a formal international
health regulation” [14]. Even as Cold War tensions receded, high-income Western states con-
tinued to challenge WHO under a “neoliberal” approach to international development, shift-
ing international health funding away from WHO and toward new vertical initiatives with
more narrow mandates, giving rise to an expanding landscape of global health governance
[15].
This expansion of the global health landscape at the end of the 20
th
century fragmented
WHO governance, weakening its institutional impact and sowing doubt in its international
leadership [16]. Beginning in the HIV/AIDS pandemic, states saw WHO as inadequate to lead
the global response, establishing the Joint United Nations Programme on HIV/AIDS
(UNAIDS) to coordinate efforts across the UN. Without WHO’s singular leadership, a prolif-
eration of new actors arose to address an array of health determinants–many joining together
in global public-private partnerships with corporate actors, including the pharmaceutical
industry [17]. The turn of the century saw the establishment of influential new global health
partnerships, including Gavi, the Vaccine Alliance (2000) and the Global Fund for AIDS,
Tuberculosis, and Malaria (2002). Many of these initiatives brought together a diverse range of
national governments, philanthropic foundations, transnational corporations, and interna-
tional organizations to implement disease-specific programming [18]. As WHO shifted from
the unquestioned leader in international health to a more contested role amid these new actors
in the global health landscape, the Organization has struggled to maintain its leadership in
global governance to advance health as a human right.
Human rights as a foundation of health justice
The human rights foundations of global health law were laid by the 1945 UN Charter, which
affirmed human rights as a core pillar of the UN system, and the 1946 WHO Constitution,
which proclaimed health as a fundamental human right. The 1948 Universal Declaration on
Human Rights became the fundamental UN proclamation of human rights, but it would take
nearly two decades to translate this initial UN declaration into binding legal obligations–under
the 1966 International Covenant on Civil and Political Rights and International Covenant on
Economic, Social and Cultural Rights, with the latter treaty enshrining the right to the “highest
attainable standard” of physical and mental health [19]. This right to health would become
central to political advocacy for WHO policies, programs, and practices, yet the Organization
long struggled to mainstream human rights across its governance structures [20].
Turning away from international human rights law in the 1970s, norms of equity animated
WHO’s primary health care agenda under its “Health for All” strategy. This WHO strategy
posited that “health is not a separate entity but an integral part of national development,”
which required national and international redistributions to ensure health equity through eco-
nomic development [21]. To design the contours of this socio-economic approach to horizon-
tal public health systems, WHO convened the 1978 International Conference on Primary
Health Care in Alma-Ata, USSR (now Almaty, Kazakhstan) (Fig 3), wherein states adopted the
Declaration on Primary Health Care (Declaration of Alma-Ata) [22].
WHO again came to embrace human rights law in the 1980s through its Global Programme
on AIDS, which recognized the importance of human rights protections for public health
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promotion in the early years of the global HIV/AIDS response [23]. Even as HIV/AIDS gover-
nance shifted to UNAIDS, WHO’s engagement with rights-based approaches to health would
expand in the 1990s, as the UN sought to “mainstream” human rights as a cross-cutting
approach to all its activities and programs [24]. Yet, WHO’s engagement with human rights
advanced unevenly across WHO policies and programs [25]. While the WHO Secretariat
established a Gender Advisory Panel in the 1990s to review all aspects of reproductive health
with attention to gender and rights, the Organization’s focus on race and ethnicity-based dis-
crimination would take far longer to develop. WHO framed its anti-discrimination strategy
not under binding human rights law, but rather in line with norms of social justice and health
equity [26].
WHO has come to merge its focus on “gender, equity and human rights”–mainstreaming
these “core values” together across its work to advance justice in health. By bringing together
these normative frameworks, WHO has sought to implement human rights without reference
to legally binding obligations [27]–as WHO’s technical staff are seen to be resistant to legal dis-
courses in technical programming [28]. WHO has continued to advocate for the right to health
as a political foundation for the advancement of universal health coverage, developing new col-
laborations with the Office of the UN High Commissioner for Human Rights [29]. However,
with limited WHO staff support for human rights law, human rights have often been relegated
to vague principles and preambular values, limiting their transformative potential in health
diplomacy [30].
Diplomatic negotiations to develop global health law
Global health law is developed through diplomatic negotiations, primarily among sovereign
states but now also including civil society and other non-state actors. Global health diplomacy
Fig 3. WHO director-general Halfdan Mahler addresses the international conference on primary health care
(Alma-Ata, September 1978). Republished from the World Health Organization under a CC BY license, with
permission from the World Health Organization.
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—the global negotiation, adoption, implementation, and review of legal instruments, pro-
grams, and policies—has thus become central to the development of global health law under
WHO governance [31]. The World Health Assembly is a principal forum for global health
diplomacy. In the very first Assembly meeting in 1948, state delegates successfully adopted
“Regulations No. 1 Regarding Nomenclature (Including the Compilation and Publication of
Statistics) with Respect to Diseases and Causes of Death” under Articles 21 and 22 of the
WHO Constitution, recognizing the importance of WHO regulations to standardize disease
reporting across nations and laying out requirements for state collection and publication of
causes of death [32]. The diplomatic momentum fostered by these “Nomenclature Regula-
tions” was extended shortly thereafter by the 1951 adoption of the International Sanitary
Regulations.
However, this diplomatic momentum to negotiate global health law was lost amid nearly
fifty years of WHO neglect of its normative authorities. Between the early 1950s and the turn
of the century, WHO was reluctant to exercise its normative function, instead revealing a pref-
erence for “technical products” to address specific diseases [33]. WHO’s landmark achieve-
ment–the eradication of smallpox–was achieved through international cooperation without
legal regulation [34]. While the WHO Secretariat developed a range of non-binding tools with
normative intent to influence the behavior of states, it did not formalize those activities
through law [35].
The 21
st
century would bring a renewed focus on global health diplomacy as a basis for the
development of global health law. In advancing hard law, the negotiation and adoption of the
2003 FCTC was pivotal–for the first time ever, the World Health Assembly launched a treaty-
making process under Article 19 of the WHO Constitution [36]. The FCTC negotiations saw
widespread involvement from civil society, which played a crucial role in supporting a WHO
treaty on tobacco, imbuing the lawmaking process with participatory legitimacy and multina-
tional advocacy (Fig 4) [37].
The FCTC negotiations were followed rapidly by the revision of the IHR, the primary
WHO instrument addressing the international spread of disease. The IHR (2005) were the
result of a decade of diplomatic efforts, with negotiations catalyzed by the 2002–2003 SARS
epidemic. Drawing from regional consultations, an Intergovernmental Working Group of
WHO member states met in late 2004 to negotiate the final draft, which was adopted the fol-
lowing year by the World Health Assembly [38]. The unanimous adoption of IHR (2005)
marked a renaissance for global health lawmaking under WHO–bringing the world together
to address common health threats through global health diplomacy [39].
Yet despite the adoption of these hard law instruments, WHO has continued to pursue
global health diplomacy through soft law advancements, seeing soft law instruments as faster
and easier to adopt than international treaties, with their non-binding nature encouraging
state and non-state actors to accept them more readily [40]. While lacking binding legal obliga-
tions, these soft law instruments can sometimes serve as precursors to future treaties—as dem-
onstrated in the evolution of global tobacco regulation—overcoming diverging state interests
that could lead to a political impasse [41]. Such soft law negotiations have become necessary in
advancing global health governance beyond WHO–and across international institutions [42].
For example, advancing the “One Health” agenda has required close coordination with the
World Organization for Animal Health (WOAH), the Food and Agriculture Organization of
the United Nations (FAO), and the United Nations Environmental Programme (UNEP) [43].
Supporting sustainable development for global health has necessitated collaboration with the
International Monetary Fund, the World Bank, and other economic governance actors [44].
WHO has looked to develop partnerships with diverse institutions under soft law commit-
ments, but it will need far stronger multi-stakeholder diplomacy to respond to contemporary
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global health challenges, requiring multisectoral law reforms to address future pandemic
challenges.
Pandemic challenges galvanize needed reforms
The COVID-19 pandemic has tested the normative foundations of global health governance,
dividing the world amid a global health threat and exposing the fragility of the international
legal order. These challenges were foreshadowed by limitations of global health law in earlier
Ebola responses, leading to the establishment of new multilateral policy initiatives to advance
global health security–within and beyond WHO governance [45]. While WHO was intended
to lead global coordination in public health emergencies, unilateral national measures violated
IHR obligations and undermined WHO governance in the COVID-19 response, galvanizing
necessary global health law reforms.
The COVID-19 pandemic exposed limitations of WHO governance under the IHR (2005)
[46], as seen in:
1. Reporting public health risks to WHO–Although the IHR require transparency and rapid
notification about public health risks, China delayed reporting to WHO, repressed
Fig 4. WHO director-general Gro Harlem Brundtland joining civil societyin advocating for the adoption of the FCTC (Geneva, October 2002).
Republished from the World Health Organization under a CC BY license, with permission from the World Health Organization.
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warnings from non-governmental sources, and withdrew information in global databases,
drawing international criticism (Fig 5) [47].
2. Coordinating national responses commensurate with public health risks–Once WHO
declared a Public Health Emergency of International Concern (PHEIC), numerous national
governments neglected WHO guidance, infringed human rights, and imposed travel bans,
fracturing an interconnected world [48].
3. Supporting global solidarity in a common response–Despite WHO efforts to rally global soli-
darity in the pandemic response, states neglected the long unrealized promise of interna-
tional collaboration to build public health capacities and resisted new voluntary
commitments to support coordination mechanisms and partnerships such as the Access to
COVID-19 Tools (ACT) Accelerator [49].
WHO has continued to face challenges in efforts to ensure vaccine equity, with the pan-
demic response yielding to “vaccine nationalism” over vaccine supply, technology, and intel-
lectual property, as states violated human rights obligations to realize equitable access to
medical resources [50]. Notwithstanding strong statements from WHO that COVID-19 was a
Fig 5. WHO director-general Tedros Adhanom Ghebreyesus meets with Chinese president Xi Jinping (Beijing, January 2020). Republished from the
Associated Press under a CC BY license, with permission from the Associated Press.
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public health emergency and access to vaccines was a human rights imperative, many high-
income states failed to participate in these solidaristic measures, and their continuing defense
of intellectual property rights through the World Trade Organization (WTO) remains at odds
with international obligations under WHO governance [51]. Efforts to limit waivers of the
WTO Trade-Related Aspects of Intellectual Property Rights (TRIPS) and other legislative
infrastructure maintaining the proprietary nature of these technologies have been barriers to
the development of local manufacturing capacity–discouraging states with existing capacity
from utilizing flexibilities under TRIPS to produce needed vaccines [52]. These compounding
injustices in the COVID-19 response have led WHO member states to launch intergovern-
mental negotiations to reform global health law, laying a new foundation for binding interna-
tional law in global health governance.
States are now pursuing twin law reforms to strengthen WHO governance—through both
amendments to the IHR and the development of a novel pandemic agreement—with these
reforms reinforcing each other to shape efforts to prevent, prepare for, and respond to future
pandemics [53]. Where past reform efforts have faced challenges from WHO member states,
these ongoing law reforms, taking place amid the COVID-19 pandemic, reveal renewed recog-
nition of the need for binding legal mechanisms to foster global collaboration and prepared-
ness for future public health emergencies.
WHO member states have proposed hundreds of amendments to the IHR that would sub-
stantially expand their scope and functions. States in the Working Group on the IHR are cur-
rently negotiating key provisions [54], including prompt and transparent reporting, scientific
data sharing (including pathogen samples and genomic sequencing data), support for low-
and middle-income countries, equitable access to medical countermeasures, and evidence-
informed and rights-based public health measures [55]. If the World Health Assembly adopts
these IHR amendments under Article 21, they would automatically enter into force for all
WHO member states unless a state explicitly rejects the amendments or submits a reservation
[56].
Yet, as the IHR obligations focus on outbreak detection and response rather than underly-
ing disease prevention systems and medical countermeasures, [57] states have called for the
negotiation of a separate pandemic agreement [58].
Thus, alongside the IHR amendments, states have called for a separate “convention, agree-
ment, or other international instrument”–in what has become known as the Pandemic Accord,
Pandemic Treaty, Pandemic Agreement, or CA+. This pandemic agreement would comple-
ment, rather than replace, the IHR, detailing new obligations to address limitations in global
health governance and advance legal authorities that are more effective, equitable, and enforce-
able [59]. In 2022, an Intergovernmental Negotiating Body [60] convened by the World Health
Assembly determined that this new global health law instrument will be negotiated as a con-
vention under Article 19, with both legally binding and non-legally binding provisions, draw-
ing on the FCTC model to become the second treaty developed under WHO [61].
Although harmonizing norms across an amended IHR and a pandemic agreement has
proven challenging, these simultaneous reform processes present groundbreaking opportuni-
ties to renew global health law in pandemic prevention, preparedness, response, and recovery.
The World Health Assembly has recognized the narrow window for its diplomatic efforts and
seeks to conclude these interconnected negotiations in the coming months. As the most
sweeping global health law developments in the past 75 years, these reforms must learn from
past legal obstacles in providing for coordinated obligations across the global health gover-
nance landscape, legally-binding norms of human rights and health equity, and diplomatic
negotiations that facilitate the meaningful inclusion of civil society–ensuring that necessary
reforms strengthen WHO governance [62].
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Necessary reforms: Global health law to strengthen WHO
governance
These legal instruments have focused global attention on WHO leadership in health emergen-
cies, but additional reforms will be necessary to strengthen WHO governance and provide
legal authorities to meet its constitutional mandate.
Translating technical support into normative instruments
While WHO has historically presented itself as a technical organization, contemporary chal-
lenges demand normative authorities. The world is facing pressing health threats that could
best be addressed through binding norms, including the looming threat of antimicrobial resis-
tance, the backlash against sexual and reproductive health, and the health impacts of climate
change [63]. WHO has vast technical expertise on these matters, but this expertise must be
translated into normative guidance for member states, international organizations, civil soci-
ety, and other partners. Decades of public health research preceded major legal breakthroughs
like the FCTC and the International Code of Marketing of Breastmilk Substitutes, but in the
absence of normative instruments, initial research often led only to incremental recommenda-
tions [64]. With states neglecting WHO recommendations, as seen in temporary recommen-
dations in the COVID-19 response, the Organization now has an opportunity to exercise its
normative function–to set global standards and facilitate accountability for state compliance.
Mainstreaming equity and rights
WHO governance must center human rights obligations in global health law, advancing equity
under global health policy and harmonizing human rights law and global health law to realize
the right to the highest attainable standard of health. Overcoming human rights limitations in
the COVID-19 response [65], a pandemic agreement rooted in human rights would detail
obligations under the right to health to prepare for future pandemics (within and beyond the
health sector), clarify human rights limitations in a public health emergency (to ensure that
any rights infringements are necessary and proportional), and obligate states extraterritorially
to provide international assistance and cooperation (to facilitate vaccine equity and global soli-
darity) [66]. With new tools to frame national health equity programs of action [67] and
human rights in public health emergencies [68], an equity- and rights-centered global health
law instrument would provide binding obligations to ensure justice in pandemic prevention,
preparedness, recovery, and response.
Sustainable and flexible financing
Beyond these legal obligations, WHO needs sustainable financing to replace the unpredictable
funding streams that have characterized its history and politicized its work. Financing reforms
must expand the sources and flexibility of WHO funding. Innovative reforms could include
increased assessed contributions commensurate with WHO’s global mandate; replenishment
conferences like those used by the Global Fund; revised purchasing policies that better provide
cost effectiveness; increased program support fees; and partnerships for concessionary pricing
[69]. In 2022, the World Health Assembly took a promising initial step toward sustainable
financing by resolving to rebalance the ratio of assessed to voluntary contributions by 2030,
and in 2024, the Executive Board agreed to plan for an “investment round” to ensure WHO’s
base budget in line with its General Program of Work. These decisions begin to provide WHO
with sustainable resources necessary to focus on the priorities decided collectively by the
Assembly–rather than those of individual donors.
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A “One Health” strategy
Expanding WHO’s global health mandate, the health paradigm at the center of WHO’s role
must evolve beyond the health of humans. “One Health” approaches to pandemic prevention,
preparedness, and response recognize that human health is interconnected with the health of
animals and our shared environment. WHO has been a crucial partner in the “Quadripar-
tite”–an inter-organizational alliance among WHO, WOAH, FAO, and UNEP–to issue joint
action plans and technical guidance on One Health. Yet, this collaboration across sectors must
be strengthened under law. The proposed inclusion of One Health in global health law reforms
can provide stronger normative grounding for WHO efforts at the center of this multi-sectoral
and inter-organizational approach to global health law–including stricter regulation and over-
sight of illicit wildlife trade, industrial agriculture, and environmental threats [70].
Good governance
Good governance seeks to apply principles of accountability, transparency, participation, soli-
darity, and equity to global health governance. WHO has made notable strides toward trans-
parency and participation in policymaking, most notably through the 2016 adoption of its
Framework of Engagement with Non-State Actors (FENSA). However, FENSA has been
widely criticized, with scholars and advocates critiquing the ways in which civil society organi-
zations and multinational corporations are treated in the same way [71]. Where private sector
influence has undermined trust in the Organization at difficult times, further reforms will be
necessary to ensure inclusive participation, including more proactive public disclosure of par-
ticipants in important meetings and committees, terms of agreements with private sector part-
ners, and commitments to transparency in internal operations. Such governance reforms can
preserve trust in WHO leadership, with meaningful civil society engagement informing WHO
decision-making and elevating public support.
Drawing from past struggles, these reforms will require efforts to revitalize hard law author-
ities in global health, strengthen WHO leadership across the global governance landscape,
uphold equity and rights at the center of global health law, and expand negotiations in global
health diplomacy.
Conclusion: Ensuring global governance under global health law
WHO has confronted unprecedented challenges over the past seventy-five years, and it will be
necessary to strengthen global health governance to face future challenges through global
health law–looking to past successes and missed opportunities in deploying hard law authori-
ties, coordinating multisectoral actors, mainstreaming human rights norms, and engaging in
inclusive diplomacy. Reforms are urgently needed to realize the promise of WHO’s normative
function, but as WHO prepares for future global health challenges, member states find them-
selves at a crossroads in the development of global health law–either to accept the divisive
responses that have characterized the response to COVID-19 or to recommit to international
cooperation through WHO governance. The next generation of global health governance will
be born from the coming reforms of global health law.
Acknowledgments
The authors are members of the Global Health Law Consortium, bringing together leading law
faculty throughout the world to develop the academic field of global health law; provide
authoritative interpretations of legal instruments in global health; and facilitate collaborative
global health law research projects.
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Author Contributions
Conceptualization: Lawrence O. Gostin, Benjamin Mason Meier.
Visualization: Benjamin Mason Meier.
Writing – original draft: Lawrence O. Gostin, Benjamin Mason Meier, Safura Abdool Karim,
Judith Bueno de Mesquita, Gian Luca Burci, Alexandra Finch, Eric A. Friedman, Brigit
Toebes, Pedro Villarreal.
Writing – review & editing: Lawrence O. Gostin, Benjamin Mason Meier, Safura Abdool
Karim, Judith Bueno de Mesquita, Gian Luca Burci, Danwood Chirwa, Alexandra Finch,
Eric A. Friedman, Roojin Habibi, Sam Halabi, Tsung-Ling Lee, Brigit Toebes, Pedro
Villarreal.
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