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International institutional legitimacy and the World Health Organization
  1. Jennifer Prah Ruger
  1. Correspondence to Jennifer Prah Ruger, University of Pennsylvania Perelman School of Medicine; jenpr{at}

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The global health community continues to look to the World Health Organization (WHO) to solve current global health governance (GHG) problems. Until the 1990s, nation-states and multilateral organisations with state members governed international health, and WHO played a prominent role, coordinating worldwide efforts such as smallpox eradication with a few partner organisations. WHO also provided international reporting and handled disease outbreaks through the International Health Regulations. The world still sees WHO as the leading global health governor, and proposals abound to reform it,1–4 to use its treaty abilities more regularly and to give it enforcement powers—all in the absence of real institutional alternatives.

But today's WHO is a compromised institution; some interrogate its relevance altogether2 and WHO Director-General Margaret Chan herself questions WHO's ability to respond to global health challenges.5 On a theoretical level, WHO lacks a substantive justice oriented conception of international institutional legitimacy. On a more pragmatic plane, WHO is riddled with budgetary weaknesses, power politics and diminishing reputation and effectiveness. WHO's early successes were laudable and the organisation has the potential to make an impact on future global health problems, but the institution lacks a number of key ingredients of success: coordination capacity, authority, accountability, fairness, a master global health plan, effectiveness and credible compliance mechanisms.

While WHO reforms could help it do its job better, a new vision, based on a substantive conception of justice and legitimacy, and associated reforms in the broader GHG system will more effectively and efficiently serve GHG functions and the WHO itself. WHO Director-General Margaret Chan states “[t]he level of WHO engagement should not be governed by the size of a health problem. Instead it should be governed by the extent to which WHO can have an impact on the problem. Others may be positioned to do a …

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  • Funding The author thanks the Whitney and Betty MacMillan Center for International and Area Studies at Yale for support.

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.