By International Health Reform Project at Brownstone dot org.

[This report of the International Health Reform Project is more than a year in preparation. The full policy report and technical reports are embedded below this foreword and executive summary. The policy report is also available from Amazon in physical and digital forms. The IHRP is sponsored by Brownstone Institute, which had no involvement in forming contents and conclusions.]

International cooperation on health is a widely accepted global good. Capacity building and development assistance reduce historic health inequalities and, as a result, strengthen economies. Management of cross-border infectious disease threats is best done through joint surveillance, data sharing, and response.

Collaboration on norms and standards provides efficiencies and facilitates trade in health products. However, the interaction between disease, the environment, and human populations is complex, and threats are heterogenous in their effects and gravity. Collaboration must therefore take such variability into account, with decision-making ultimately based around those affected.

Experience has demonstrated that international health cooperation can, when poorly governed, undermine trust, distort priorities, and produce significant unintended harm. Recent trends of centralized decision-making, emergency exceptionalism, and donor-driven agendas, exemplified during the Covid-19 response, displaced proportionality, local context, and established public-health ethics. These failures revealed structural weaknesses rather than temporary lapses.

At the same time, cooperation in public health also requires an understanding of the sovereignty and equality of individuals, and of the states that represent them – an understanding that underpins the United Nations itself. Thus, any institution tasked with managing health cooperation must be based on this understanding and be fully subject to the states it is intended to serve.

It should surprise no one that, after nearly 80 years of existence in a greatly changed world, the World Health Organization (WHO) is perceived by many to have drifted from its original model. Fundamental shifts in its funding base, and now the exit of its largest state funder, present both an opportunity and an urgency to reassess the optimal way in which states should work together to serve the health needs of their populations, applying the fundamental principles on which public health should be based to a greatly changed and evolving world.

WHO and the state of international health cooperation

The WHO constitution, signed in 1946 by 51 states then comprising the United Nations, had little input from most current African and Asian states. Its governing body, the World Health Assembly, gradually expanded as states broke from colonialism or foreign mandates to achieve sovereignty.

Defining health in its constitution as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity," the WHO took on a broad mandate including support for these less-resourced states, coordinating cross-border outbreak management, disease elimination, and the setting of international normative standards. It was hoped that the improvements in health and longevity that economic development had brought to wealthier countries could be accelerated in the lower income countries, reducing the inequalities resulting from colonialism and neglect.

The WHO's 150 country offices have formed a framework to strengthen local capacity and health systems. The organization is well known for successes such as smallpox eradication and early focus on the major drivers of well-being and longevity such as improved sanitation, nutrition, and access to basic healthcare. Major programmes in tuberculosis, malaria, vaccination, and child health have set standards for disease management and reduced overall disease burdens. A global decline in infectious disease mortality, con...