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Volume 43
Issue 2
March 2024


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THE WORLD HEALTH ORGANIZATION AS AN ENGINE OF IDEATIONAL ROBUSTNESS

Jean-Louis Denis,
Jean-Louis Denis
School of Public Health, Université de Montréal
, 7101 Av du Parc, Montréal, Québec H3N1X9,
Canada
Corresponding author: Jean-Louis Denis. Email: jean-louis.denis@umontreal.ca
  https://orcid.org/0000-0003-1295-332X
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Gaëlle Foucault,
Gaëlle Foucault
Faculty of Law, Université de Montréal
, Montréal,
Canada
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Pierre Larouche,
Pierre Larouche
Faculty of Law, Université de Montréal
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Catherine Régis,
Catherine Régis
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, Montréal,
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Miriam Cohen,
Miriam Cohen
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Marie-Andrée Girard
Marie-Andrée Girard
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This paper was submitted to the Special issue proposal of Policy and Society:

Ideational robustness: Robust policy ideas in turbulent times

(Martin B. Carstensen, Eva Sørensen and Jacob Torfing, Roskilde University).

Author Notes
Policy and Society, Volume 43, Issue 2, March 2024, Pages 204–224,
https://doi.org/10.1093/polsoc/puae008
Published:
05 March 2024
Article history
Received:
31 August 2023
Revision received:
09 January 2024
Editorial decision:
28 January 2024
Accepted:
27 February 2024
Corrected and typeset:
05 March 2024
Published:
05 March 2024

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   Jean-Louis Denis, Gaëlle Foucault, Pierre Larouche, Catherine Régis, Miriam
   Cohen, Marie-Andrée Girard, The World Health Organization as an engine of
   ideational robustness, Policy and Society, Volume 43, Issue 2, March 2024,
   Pages 204–224, https://doi.org/10.1093/polsoc/puae008
   
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ABSTRACT

The paper focuses on the role of the World Health Organization (WHO) in
promoting a healthy world population as a generative and robust idea within
health policy. The WHO’s health credo transcends national boundaries to promote
health globally. It is embedded in norms, values, and standards promulgated by
the organization and contributes in shaping the health responses of national
governments. Ideational robustness refers to the ability of the WHO to adapt its
health credo to changing contexts and circumstances, thus promoting the
legitimacy of an international health order. Disturbances, including the
Covid-19 pandemic, test the credo’s robustness, forcing the WHO to constantly
work at reframing ideas to adapt to political forces and competing logics that
structure the field of international health. Empirically, the paper is based on
an historical analysis of the evolution of the health credo of the WHO since its
inception. Qualitative content analysis of secondary sources, such as policy
documents, explores how ideational work performed by WHO leaders impacts on the
organization’s position and legitimacy. Ideational robustness appears to be
largely influenced by leadership vision, preexisting organizational structure,
and the political economy of international health. Ideational robustness appears
as a powerful yet insufficient ingredient of policy success.

ideational robustness, international organizations, world health organization,
health policy, institutional work
Issue Section:
ORIGINAL RESEARCH ARTICLE

The importance of ideas has long been recognized in policy science (Béland,
2005, 2016; van Gestel et al., 2018). Ideas participate in the definition of
policy problems and solutions, convey assumptions about needed changes and
reforms, and inspire debate and controversy that shape the becoming of policies
and institutions (Béland, 2009). In the last two decades, numerous works have
focused on sources of robustness in policymaking (Capano & Woo, 2017, 2018).
Robustness is defined as an instance of dynamic conservatism through which a
system bounces forward to maintain some of its key functions in new and perhaps
more attractive ways (Ansell et al., 2023, p. 9) in response to disruptive
events and challenges. Within this intellectual movement, ideational robustness
focuses on the adaptability and innovative characteristics of policy ideas in
challenging contexts (Capano & Woo, 2017). Because of the centrality of ideas in
institutional development and evolution, it is important to understand how ideas
evolve through time in situations where stabilization and destabilization
prevail. Tracking the reframing of ideas in both situations helps understand the
role of ideational robustness in the renewal of institutions, governance and
policy-making, and the mechanisms that support adaptive and transformative
reformulation of core policy ideas.

This paper looks at the manifestations and determinants of ideational robustness
within the World Health Organization (WHO). The WHO, part of the United Nations
system, is the only international intergovernmental organization entirely
dedicated to health matters, with a broad and ambitious objective: “the
attainment by all peoples of the highest possible level of health” (WHO
Constitution, 1946, Article 1). This objective is the bedrock of ideational
robustness, the WHO “credo.” The WHO periodically revisits this credo and the
core policy elements derived from it, in order to face new challenges and
negotiate the contested terrain of international diplomacy and the politics of
sovereign States. As we will see, since its creation in 1946, the WHO has, at
various moments, reformulated, and reinterpreted its credo to achieve a balance
between continuity and change in core policy ideas. This is particularly
important for the WHO as an international organization with limited levers to
impose policies or orientations on sovereign States (Gostin et al., 2015). The
legitimacy of the institution and its ability to exert influence rely
significantly on its ability to formulate, reformulate, and defend attractive
and relevant ideas in the international health field. The robustness of these
ideas can never be taken for granted; achieving robustness requires constant
efforts that become more intense during challenging times.

We contend that the WHO has successfully tied its fortunes to its “health”
credo—“health” being an abstract ideal almost impossible to oppose—by enshrining
its position as a point of reference for health worldwide during times of both
calm and crisis—a strategy that appears at the core of WHO responses to
disruptive events. Our empirical findings suggest that the WHO has, over time,
reshaped its health credo with different emphasis, from “international public
health” to “international health solidarity” to “global health”, in such a way
as to maintain its relevance and legitimacy in the face of changing contexts and
increasing competition among various organizations in the global health area. We
focus on the generative potential of the health credo seen in the WHO’s core
program decisions, policy documents, and normative instruments, to respond to
external shocks and disturbances within the constraints imposed by its
organizational structure. Ideas are thus considered a powerful ingredient of
policy success that is nevertheless insufficient for achieving ambitious
policies.

Our research builds on the assumption that ideational robustness can be used to
bolster WHO legitimacy and uphold its position, and asks two main questions: (a)
How does WHO leadership achieve ideational robustness in the face of shocks and
disturbances? and (b) How do efforts to achieve ideational robustness relate to
changes in programs and strategies?


CONCEPTUAL BACKGROUND


IDEATIONAL ROBUSTNESS AS A CORE POLICY CAPACITY

Achieving ideational robustness can be conceived as a core policy capacity,
where the attention given to ideas contributes to the relevance and adaptation
of institutions in both routine and challenging situations.

We approach the problem of ideational robustness from the perspective of
scholarly works on agency and change within institutions. Ideational robustness
is considered here as the product of interactions and strategies that promote a
set of views within the field of international health. One of the strengths of
neo-institutionalism is in recognizing the purposeful and effortful
institutional work performed by actors to create, maintain, or change
institutions (Hampel et al., 2017; T. B. Lawrence & Suddaby, 2006). Work
performed to change or adapt core ideas (ideational work) in challenging times
is one form of institutional work.

Various typologies of institutional work have been proposed (Hampel et al.,
2017; T. B. Lawrence & Suddaby, 2006) to identify how agents conditioned by
institutional rules and norms develop practices to preserve, innovate or reframe
institutions. Studies have also shown that organizational leaders play a key
role in efforts to adapt institutions (Hampel et al., 2017; T. Lawrence et al.,
2013). In an empirical analysis of reforms in highly institutionalized settings
such as publicly funded health systems, Cloutier and colleagues (2016) propose a
classification of institutional work around four broad categories: conceptual
(ideational) work, structural work, operational work, and relational work. We
believe this classification is equally relevant for the study of institutional
work in an institutionalized setting at international level, such as WHO health
policy work. These categories are retained because they consider both the
importance of ideas in policymaking, and a set of other factors involved in
efforts to adapt organizations and institutions to major disturbances. They are
used here to track the evolution of the WHO health credo and its ability to
simultaneously face disruptive challenges and more routine demands (Ansell
et al., 2023).

Conceptual (or ideational) work is performed by agents engaged in defining and
redefining core ideas—such as “a healthy world population”—(Cloutier et al.,
2016) in order to arrive at meanings that are sufficiently polysemic to gain
support from a wide variety of actors, groups, and organizations with a
diversity of values and interests (Sørensen & Ansell, 2023). In turbulent times,
leaders will reconsider the meaning and framing of core policy ideas or goals
(Howlett & Ramesh, 2023), and attempt to realign short-term demands and
constraints with long-term responses to disruptive and evolving challenges (Pot
et al., 2023).

While it is difficult to assign precedence, we conceive ideational work as
playing a predominant role in shaping the destiny of organizations and policies.
As a starting point, we posit that ideational work occurs through many
mechanisms: Rebalancing ideas, incorporating new elements, and re-articulation
(see call for contributions for this special issue). Rebalancing refers to
altering the weight of various policy ideas, as seen, for example, in growing
emphasis on the importance of national health systems within the WHO health
credo. The incorporation of new elements serves to adapt policy to disturbances,
as with the WHO’s decision to integrate veterinary public health as a core
policy area. Re-articulation refers to changing or expanding the meaning of
policy ideas. For example, the meaning of international solidarity in the WHO
health credo evolved from cooperation of sovereign States sharing common ideals
to multiple partnerships between States, the WHO and private partners. It is
expected that these mechanisms will produce ideational robustness and contribute
to robust governance and institutions (Ansell et al., 2023).

However, ideational work is not performed in a vacuum. In our analysis, we
consider that ideas are constrained, supported, or nurtured by the networks of
actors in place in the field of international health (Zietsma et al., 2017). The
other three categories put forward by (Cloutier et al., 2016)—namely structural,
operational, and relational work—take place within these networks and combine
with ideational work to confer power and legitimacy to ideas.

Structural work refers to efforts to establish formalized roles, rule systems,
and resource allocation models in support of an idea, and thus contribute to its
robustness. For example, to respond to a health crisis and maintain its
leadership or coordinating role, the WHO may establish ad hoc scientific
advisory committees to support its policies or decisions (Gaille et al., 2020;
Rajan et al., 2020). Operational work refers to concrete actions to accomplish
the organization’s main program of work, such as moving from projects that aim
to eradicate a single disease to projects that focus on the broad causes of
disease and poor health. And finally, relational work, which underpins the other
three, refers to efforts to build linkages, trust, and collaboration between
organizations involved in international health. For example, in recent times,
strategies were developed to increase collaboration with private partners around
specific health priorities.

It is expected that, faced with shocks and disturbances, WHO leaders will engage
with greater intensity in all types of institutional work to substantiate the
organization’s health credo, reassert its relevance and appeal, and improve its
robustness. Our approach emphasizes the dialectical and reciprocal relationships
between the ideational component of institutional work and its other components
both in routine and turbulent contexts or situations.


ORGANIZATIONAL AND POLITICAL CONTEXT OF IDEATIONAL WORK AT THE WHO

As proposed by Ahrne et al. (2016), international organizations like the WHO are
better seen as “meta-organizations” than as typical organizations based on the
membership of individuals. Members of meta-organizations are not individuals but
organizations; in the case of WHO and other international organizations, these
members are sovereign States with their own interests, values, and capacity to
influence decisions (Ahrne et al., 2016). As a “meta-organization,” the WHO
therefore competes with its own members for influence. Furthermore, the presence
of strong regional organizations within the WHO reinforces its character as a
meta-organization; some authors go so far as to characterize the WHO as a
“federation” of regional organizations (Graham, 2014; Hanrieder, 2015). In order
to manage collaboration and competition among members in a meta-organization,
decision-making is more consensual. As it is difficult for leadership to impose
decisions or strategic orientations, the WHO often adopts a diplomatic approach
and cannot easily impose policies or priorities.

Moreover, the WHO continually faces challenges to its health credo, whether from
major health crises such as a world pandemic or from the political volatility
and complexity of the international health order. Achieving ideational
robustness is a constant struggle due to the multiple sources of disturbances,
emphasizing the importance of the diversity and inclusivity of ideas (Sørensen &
Ansell, 2023). The inherent pluralism of international meta-organizations
represents a challenge for their governance and effectiveness. Gostin et al.
(2015) identify a set of constraints that may also limit WHO effectiveness, such
as a paucity of resources, earmarked funding that limits agility, excessive
regionalization, expectations that it will serve member States, and the ability
of autonomous states to exert dominant power over the organization’s destiny
(Fligstein, 2005; McInnes, 2015). Graham (2014) and Hanrieder (2015) see WHO
regional organizations a major source of fragmentation for the organization that
undermines its ability to act with unity. These constraints limit the WHO’s
ability to engage in global health governance, and naturally nudge the WHO
towards using ideas to compensate its limited power. Maintaining its role as
world health leader is challenging for the WHO considering that its constitution
and predominant approach to health issues are based on collaborative work with
governments and sovereign States (Dodgson et al., 2009). While a crisis like the
Covid-19 pandemic may exert a strong disruptive pull (Capano et al., 2022),
external and internal contingencies mean there is no guarantee that an
organization like the WHO will be able to operate the necessary changes (Boin &
‘t Hart, 2022). On the one hand, the health credo promulgated by the WHO is
subject to continuous negotiation and reinterpretation through the political
dynamics inherent to meta-organizations, which can undermine ideational
robustness. On the other hand, when a majority of states supports an idea, this
enhances ideational robustness and gives the WHO a unique strength in the field
of international health.

Finally, there is also a risk that the health credo becomes decoupled from the
WHO’s capacity to materialize it. The field of international health has been
progressively inhabited by powerful players, which impacts the WHO’s legitimacy
as the core steward of global public health (Clift, 2014; Kickbusch & Szabo,
2014; Ruger & Yach, 2009; Taylor & Habibi, 2020). For example, the Bill and
Melinda Gates Foundation plays a significant role in global health, sometimes
complementing the WHO, but sometimes also substituting for it. Moreover, the
growing role of private partnerships in the development of global health
governance, based in principle on multidisciplinary and multi-sectoral
approaches to health problems (Youde, 2017), has somewhat counter-intuitively
favored the resurgence of a narrower often disease-specific approach to health
(Ruckert & Labonté, 2014). Within the WHO, there is thus a constant tension
between disease-specific approaches that aim to address underlying causes of
disease, and a view of health disparities as a symptom of the prevailing global
political economy (Thomas & Weber, 2004). Leaders must reconcile competing views
in their quest for coherent and robust policy ideas in both more routine and
crisis situations.

Overall, based on the literature on policy robustness, institutional work and
international organizations, and international relations, the WHO’s status as
steward of a healthy world population depends not only on its efforts to provide
clarity around its health credo, but also on its ability to adapt its
aspirations and credo to a changing context. Ideational work appears as a
necessary, possibly predominant, but still insufficient condition for the WHO to
maintain its position within the evolving field of international health.
Attention must also be paid to other categories of institutional work that
accompany ideational work. In addition, ideational work, and ultimately
ideational robustness, cannot be understood without due attention to the field
of international health as a contested terrain and to the WHO’s specific
meta-organizational and quasi-federated form (Hanrieder, 2015). Our proposed
approach to analyzing the role of ideas in fostering robust institutions and
governance bridges micro-dynamics, embodied in the roles and interventions of
WHO leaders, the influence of its specific organizational form, and the more
distal context of the political economy of international health.


RESEARCH METHODOLOGY

Our contribution in this paper is to empirically probe the evolution of the WHO
health credo in a context where core programmatic decisions and relational
strategies are developed to promote ideational, and hence institutional,
robustness. We rely on a longitudinal and retrospective case study to document
ideational work and changes undertaken by the WHO since its creation in 1946.
Case study is an appropriate research design (Hampel et al., 2017; Lawrence &
Suddaby, 2006) to understand the process of change in a context characterized by
distributed agency and social determinisms (Reed, 2009). While scholarly works
on robustness and ideational robustness emphasize their importance in turbulent
times and challenging contexts, we argue that the adoption of a processual and
historical approach that looks at the framing and reframing of ideas in both
situations of stabilization and destabilization helps understand how ideas
evolve through time and their impact on the destiny of policies and
organizations. In the case of the WHO, the occurrence of crises—if only because
of public health events of concern such as pandemics—is a given, even if their
timing and location cannot be predicted. Therefore, institutional work designed
to foster ideational robustness is usually undertaken against a backdrop of
previous and anticipated crises, even if such work takes place during a calmer
time. Hence, it is valuable to study such work over time, not only during crises
but also outside of them. Our approach is influenced by the idea of incremental
reasoning in policy analysis (L. D. Brown, 2010) where past orientations
influence the framing of new ideas, and eventually their ability to orient and
prompt action. Concretely, we segment our case into three periods where tensions
and challenges of varying intensity emerge and precipitate shifts in the framing
of the WHO’s health credo.

Our principal source of empirical data is gray literature (foundational, basic,
and policy documents produced by the WHO between 1946 and 2023). An initial
document search on the WHO website provided a rich source of information. We
identified four extensive reports covering the first 40 years of WHO activity
(WHO, 1958, 1968, 2006, 2008). Beyond this period, three approaches were used to
identify documents and track similar information. First, the importance of
Directors General in the direction taken by the WHO (see further) led to a
targeted search for “major” speeches by Directors General since 1990 (notably,
their first and last speeches and speeches at major events). We also included
WHO Annual Health Reports for the years 1995–2008, 2010, and 2013 based on
availability of information. Finally, for the years 2000–2023, a more targeted
search was carried out for statements and documents surrounding landmark WHO
events [e.g., adoption of the International Health Regulations (IHR), the
Tobacco Convention, and documents produced during the Covid-19 pandemic,
including the 15 statements of the IHR Emergency Committee]. These sources were
supplemented with the study of key WHO normative instruments, such as the IHR
and the Tobacco Convention, and with a literature search using Google Scholar
for key peer-reviewed sources on the analysis of the role and evolution of the
WHO.

We undertook content analysis of these documents, dividing up documents among
the research team (co-authors of this paper) for each 10-year period. We then
held regular team meetings to discuss our interpretation of the data and
identify key dimensions in the representation of health promulgated by the WHO
and what these implied for the organization, its activities, and partnerships.
We used temporal bracketing (Langley, 1999) to delineate shifts in the health
credo precipitated by an accumulation of significant changes in international
health as an organizational field. Three periods were empirically identified
(see Figure 1). Material from scholarly works on the evolution and roles of the
WHO were used to validate and enrich our interpretation. Figure 1 presents an
operational model of WHO ideational work and robustness within prevailing
material and political conditions. It suggests that ideas play a fundamental
role but that there must also be alignment between organizational structure,
operations and relations, and external forces. Ideational robustness to respond
to shocks and disturbances appears as a product of this alignment.

Figure 1.

Developmental phases of the WHO: ideational work and robustness.

Open in new tabDownload slide


EMPIRICAL FINDINGS


THE EVOLUTION OF THE WHO HEALTH CREDO

It was within the context of a “new age” after the Second World War that States
decided to create a new international organization entirely dedicated to health.
Meeting in New York in 1946 for the International Health Conference, States
adopted the founding treaty of the WHO, the WHO Constitution, and the WHO began
its activities in 1948. The WHO can be viewed as the expression of this “new
age” spirit embodied in the United Nations Charter, which is characterized by
two main imperatives: the quest for stable peace and security and for a stronger
promotion of human rights. Indeed, from the first lines of the preamble, health
is understood as a fundamental condition “to the attainment of peace and
security” and the “enjoyment of the highest attainable standard of health” as a
fundamental right. This “new age” spirit also appears in the definition of
health in the opening section of the WHO Constitution: “a state of complete
physical, mental and social well-being.” Drafters of the WHO Constitution
adopted that “positive and broad” health credo, rather than a “negative and
strict” definition of health, namely the absence of disease or infirmity (WHO,
1948, p. 17). This definition cannot be separated from the context in which it
was formulated: the “urgent task … to fight for the physical and mental health
of the human community” after the war (WHO, 1948, p. 96). This marked a break
from prior international health institutions1, which focused mainly on
communicable diseases (Burci & Vignes, 2004, pp. 15–16). From its inception, the
WHO was thus expected to deal with “broader issues of global public health”
(Rey, 2021, p. 140).

Over the next 75 years, this initial definition would be enriched, with numerous
ramifications. Figure 1 presents ideational work performed by the WHO during
these years within the evolving institutional and political context of
international health. As stated earlier, ideational work and its impact on
ideational robustness is contingent on the performance of structural,
operational, and relational work within different periods characterized by
challenges of various intensity. This is reflected in Figure 1 and in the
narrative further. Attention to this configuration of institutional work aims to
help grasp through time the drivers of ideational robustness and its impact on
policy and institutional robustness. The empirical findings are presented in
three periods (1948–1968; 1968–1988; and 1990s to the present) in the evolution
of ideational robustness in the WHO. The narrative takes the form of a
“periodization” based on various crises and changes which, in a cumulative way,
produce paradigm shifts associated with the idea of health. Our objective is to
demonstrate the guiding ideas that shaped the WHO as an international
organization through different historical periods.


THE FIRST TWO DECADES (1948–1968): INTERNATIONAL PUBLIC HEALTH

The WHO was recognized from the start as the “directing and co-ordinating
authority on international health work” (WHO Constitution, Article 2.a.), with
as first order of business the management of cross-border health crises. The
first WHO program adopted by the World Health Assembly (1948) positioned the
management of communicable diseases (malaria, tuberculosis, venereal disease)
among “top priorities” within its broader health aspirations.

However, during its first decade, the WHO approach to communicable diseases
evolved from emergency control towards prevention (WHO, 1958, p. 29) and action
on fundamental causes (WHO, 1958, p. 171). This evolution was in line with the
mandate set out in the WHO Constitution, as mentioned earlier. At the time, the
WHO framed its health credo as international public health, seen as a promising
idea to translate constitutional aspirations on public health into
organizational priorities.

The programmatic consequences of this idea of international public health were
evident in WHO attention to planning, research, and assessment of Member State
needs. The WHO quickly developed functions relating to the distribution of
technical assistance (Article 2.d.), health research (Article 2.n.), teaching
and training (Article 2.o), counselling and assistance (Article 2.q.), and
public education on health (Article 2.r of the WHO Constitution). During its
first decade, the WHO developed broad assistance programs in all areas requested
by Member States, going beyond public health and medicine to also include issues
such as dental health (WHO, 1958, p. 334). The WHO also expanded from limited
projects to “comprehensive projects” at country level which focused mainly on
assistance (WHO, 1958, p. 170). The role of the WHO as “professional and
technical educat(or),” essentially with respect to the re-articulation of
communicable disease management was recognized during this period (WHO, 1958, p.
373).

The WHO remained on this path in its second decade, with continuing emphasis on
understanding state capacities. This decade also saw greater and more systematic
attention to evidence and research as core resources to design and implement
effective health interventions (WHO, 1968, p. 42).

During this period, the WHO pursued “core” health activities undertaken by
previous organizations (e.g., biological standardization, list of diseases, and
causes of death), while also undertaking activities in other health-related
areas (e.g., environment, occupational health, and national health systems) and
specific population segments (e.g., the elderly). Its idea of international
public health thus built on historical precedents, while also expanding in scope
and incorporating new elements at the core of its health credo.

From the outset, the WHO’s health credo had a holistic dimension. Beyond the
diversity of sectors included under “international public health,” the WHO also
recognized veterinary public health as a domain of activity. This multifaceted
idea of health required collaboration with other international organizations and
NGOs (WHO Constitution, Article 2.b). However, this openness to a broader
dimension of health could not yet be conceived as a “global health” perspective
(as we will see in the 1990s; Garay et al., 2013, p. 6). The emphasis was still
on the interstate dimension: collaboration of Member States with the WHO as
monitor and coordinator, and the desire for a “universal” WHO still seen as an
orchestrator of the participation of governments and States (Dodgson et al.,
2009, p. 446). Nevertheless, the path to global health was opened by recognition
of a strong policy concept already present in this period: interdependence (see
further). This concept was limited to epidemics during the WHO’s first decade
(WHO, 1958, p. 94), but would become broader in the second through recognition
of the interdependency between health and the overall development of society
(WHO, 1968, p. IX). Even in this first relatively stable period, which was
nonetheless marked by epidemics (e.g., flu pandemics in 1957 and in 1968), the
WHO paid attention to enriching and adapting its health credo in order to
maintain legitimacy in an evolving international health order.

The idea of health developed by the WHO during this first period went beyond the
management of communicable diseases to encompass new cross-border health
phenomena and new health issues. This credo was directly related to post-war
trauma and crises on numerous fronts. As illustrated in Figure 1, the focus on
communicable disease management was re-articulated when the WHO shifted its
emphasis to prevention. This ideational change led to a structural emphasis
within the organization on planning and training as well as on the relational
work to develop collaboration with international institutions working on similar
issues (see Figure 1). For example, in the field of veterinary health, which
focuses mainly on meat and milk hygiene, the WHO has worked closely with the
Food and Agriculture Organization (FAO) (WHO, 1958, p. 238). New domains were
added to WHO operations to address the preventive scope of its health credo.
Through ideational work, the WHO positioned itself as an invaluable player in
the fight against emerging post-War health challenges. Subsequent periods would
bring challenges that tested the adequacy and power of this health credo.


THE THIRD AND FOURTH DECADES (1968–1988): FROM INTERNATIONAL PUBLIC HEALTH TO
INTERNATIONAL HEALTH SOLIDARITY

During its third decade, the WHO not only maintained some elements from the
previous 20 years, such as recognition of “close interdependence between health
and other aspects of development” (WHO, 2008, p. 9), but also had to adapt to a
changing political and economic context. The idea of health promoted by the WHO
was directly challenged. First, the intensification of Cold War conflicts had a
programmatic impact. The WHO had to revisit its normative activity, which led to
a reshuffling of the agenda to favor consensual themes and projects (such as
malaria eradication, vaccination, nutritional needs, etc.) (Holst, 2020, p. 3;
Weisz & Tousignant, 2019, p. 373; WHO, 2008, pp. 5–6). Efforts in the WHO seek
to conceptualize public health as a field apart from current geopolitical
tensions. Distinct from phase I, there is an emphasis now on working through
nations with populations and individuals to improve health. Secondly, the
combined effect of the New International Economic Order (NIEO) movement and the
oil crisis pushed the WHO to rationalize its expenses (Weisz & Tousignant, 2019,
p. 375; WHO, 2008, p. 5) and consequently modify its financing of health
programs.

In particular, the NIEO prompted the WHO to re-articulate its idea of health to
a more inclusive notion of health for all (Mahler, 1981, p. 5). A greater share
of the budget was subsequently allocated to technical cooperation, which mainly
benefited the developing countries (WHO, 2008, p. 375).

The oil crisis forced the WHO to decrease its number of employees, which in turn
increased the need to collaborate with outside resources, such as Member States,
NGOs, and philanthropic organizations. These competing interests led to the
defining moment of the Declaration of Alma Ata (1978) which is placed at the
heart of WHO programs the “health for all” principle (Holst, 2020, p. 5; Lawn
et al., 2008, p. 920), derived from Article 1 of the WHO Constitution. The
promotion of “health for all” also takes root in the rise of a new public health
approach put forward by the Lalonde report in 1974 where a pledge is made to pay
attention to the determinants of health. The Alma Ata Declaration also
introduced the concept of primary health care as a privileged driver of health
improvement (Holst, 2020, pp. 5–6). The idea of health was thus recast from
“international public health” to “health for all,” presenting the idea of health
“solidarity” and inclusivity alongside a new biomedical-centric core element
which was considered easier to navigate within the socio-political context of
the 1970s (Holst, 2020, p. 6; Weisz & Tousignant, 2019, pp. 374–375).

In the 1970–1980s, financial troubles and the difficulties WHO officials faced
in responding to the “new international political economy structured around
neoliberal approaches to economics, trade, and politics” meant the World Bank,
which had become a “dominant force in international health,” gained ground (T.
M. Brown et al., 2006). This situation had relational consequences for the WHO,
which was strongly encouraged to develop joint programs in order to take
advantage of the funding available within the field of international health. For
example, in 1975, the WHO launched the Special Research Program for Research and
Training in Tropical Diseases with the help of the World Bank, the United
Nations International Children’s Emergency Fund (UNICEF), and the United Nations
Development Program (UNDP), enabling it to obtain new funding to meet the needs
of countries affected by these specific diseases (Guilbaud, 2015, p. 62).

Moreover, following the 1st International Conference on Health Promotion in
1986, the Ottawa Charter for Health Promotion was proposed, emphasizing health
promotion, defined as the process of enabling people to increase control over,
and improve, their health. The concept of “health promotion” which encourages
the empowerment of communities to control their own health embodies the “New
public health.” The latter emphasizes a “new multisectoral conception of
health,” which draws on various disciplines and fields (such as sociology,
education, economics) and focuses on essential issues like human rights, women’s
health, and development (Merson & Inrig, 2018, pp. 55–56; Tulchinsky &
Varavikova, 2014, pp. 43–45). This change in the conception of health prompted
the WHO to adapt its work, stressing, for example, the importance of
communicating directly to the public.

The “health for all” principle that fuelled the 1968–1988 period (WHO, 2008, p.
vii) was an “important and long-lasting contribution of WHO” (Burci & Vignes,
2004, p. 160) and had important programmatic implications. The modified health
credo promoted by the WHO took root in a context of economic crisis that
impacted the WHO’s room to manoeuver. In 1981, the WHO Director General
mentioned that while the climate was “chilly outside” due to “war, conflict,
economic instability, confrontation, and deadlock in the North/South dialogue,”
the Organization was “warm” inside, as there was “high expectation,
determination to attain the goal of health for all, hectic activity to define
strategies for reaching that goal, and, in this endeavour, cooperation as never
before among Member States at all stages of development” (WHO, 2011, p. 2).

Although the evolution towards “health for all” was shaped by the economic and
geopolitical context of the time, one important element promoted by the WHO was
the profile and leadership of the Director General. For instance, Dr Halfdan
Mahler (1973–1988), a strong defender of the primary health care movement (WHO,
2008, p. vii), placed major emphasis on health system development (WHO, s.
d.-b). Dr Mahler consistently advocated placing health within the broader
framework of fighting poverty which, for instance, gave rise to the adoption of
the first List of Essential Medicines (1977) to respond to the “main drug
problems facing the developing countries” (WHO Expert Committee, 1977, p. 7).

Finally, a major global health crisis, the emergence and spread of human
immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome
(AIDS), came to dominate the WHO agenda and triggered unprecedented legislative
activity in many Member States (WHO, 2011). This new threat, with no cure or
vaccine, challenged the WHO, which faced consistent criticism for ignoring and
underestimating what it saw as a “rich man’s disease” (Malher’s words in Merson
& Inrig, 2018, p. 8). Then, the extent of this virus led the WHO to restore
significant weight to the management of communicable diseases and play a pivotal
role in coordinating global efforts, despite reluctance from various Member
States to be “completely open in the matter of AIDS” (WHO, 2011, p. 269). The
WHO Special Program on AIDS was created to ensure international collaboration
and provide support to national prevention and control programs (WHO, 2011). By
1987, 127 countries had sought WHO collaboration and 151 countries had
established national AIDS committees (WHO, 2011, p. 270), showing how
reformulation of its health credo supported the WHO’s ability to intervene at
world scale. However, as emphasized by Merson and Inrig, from the very beginning
of the fight against HIV and AIDS, “WHO’s authority in coordinating the global
response was—at least on paper—complicated, contradictory, and open to
contestation” (Merson & Inrig, 2018, p. 77). Given the scale of the consequences
of this pandemic which highlighted the multisectoral approach to health
described above (e.g., Harden, 1987), the WHO needed the collaboration of other
agencies not exclusively linked to health (and to have other addressees than
ministries of health) (Merson & Inrig, 2018, pp. 77–78). For example, the WHO
and UNDP established an alliance to address the socioeconomic consequences of
AIDS. The recognition of new needs in terms of collaboration highlights the
evolution of the WHO’s concept of health (multisectoral), and the response to
such needs in the form of inter-institutional partnerships and alliances which
strengthens the solidarity principle at the heart of the idea of health promoted
by the WHO at this time.

However, the creation of various programs and bodies to combat the virus
complicated the landscape of this fight and the lack of coordination
(conflicting recommendations, competition for funding) between all of them has
affected them, as well as the authority of the WHO (Burci & Vignes, 2004, p.
84). Likewise, the rejection in practice of a more inclusive vision of health
and, ultimately, of WHO’s mandate (importance of the role of the WHO’s central,
multisectoral approach to health, and partnerships) by the new Director General
(Nakajima 1988) had a negative impact on the consistency of the WHO’s ongoing
management of the virus (Merson & Inrig, 2018, p. 116). Finally, associated in
the 1990s with the idea of health security, this pandemic had serious
consequences for the WHO and its idea of health (see further).

This second period was thus characterized by recognition of the importance of
primary health care as an inclusive political concept to nurture international
collaboration. This new element at the heart of the WHO health credo made it
possible to rebalance “crisis health” (management of communicable diseases) and
“routine health” in favor of the latter. It also provided an acceptable and
neutral ideational response to the context of the Cold War and the growing
number of new sovereign States after decolonization. In addition, the
multisectoral aspect of health and the WHO’s financial constraints, which
encouraged the emergence of competing voices and players in the field,
underlined the need for cooperation between institutions through alliances,
partnerships, and joint programs. The emergence of HIV brought the management of
communicable diseases back into the core of the WHO health credo and ultimately
had major programmatic consequences for the organization, as well as structural
(e.g., alliance strategies) and relational (e.g., new forms of collaboration
with national committees and other institutions) consequences. These new
elements in the WHO’s conception of health gave strong impetus to international
solidarity as an aspiration within the ecosystem of international organizations.
Ideational robustness was achieved by aligning the health credo with broader and
shifting political dynamics and context. This encouraged the promotion of
programs in developing countries and cooperation with civil society. Finally,
the role of the Director General and his leadership can have a major impact on
the evolution of the WHO’s idea of health or on consolidating its
rearticulation. The paradigm shift in the idea of health, from “international
public health” to “international health solidarity,” is due to a combination of
events: health crises (e.g., HIV), mutations in the international health order
(New Public Health), and internal institutional factors like the impact of the
Director General’s leadership. Their cumulative contribution to the operational,
structural, and relational aspect of the WHO led to the evolution and
consolidation of the idea of health, which became “international health
solidarity” during this second phase of the organization’s evolution (see
Figure 1).


SINCE THE 1990S: FROM INTERNATIONAL HEALTH SOLIDARITY TO GLOBAL HEALTH

The end of the Cold War ushered in a few promising years in international
relations. During this period, the terms “global health” and “global health
threats” appeared in the literature more frequently (T. M. Brown et al., 2006).
The WHO was not an early adopter, maintaining a more traditional view in the
field of international health that evolved only slowly partly due to its
commitment and habit to see governments and States as its main partners. The
tipping point came partly due to a change of Director General.

Under the leadership of Dr Nakajima (1988–1998), a traditional interstate and
pyramidal approach of international health persisted. The idea of health put
forward positioned the WHO as an authority that coordinated and monitored health
measures, assessed State needs and made recommendations to Member States. On the
surface, that traditional approach remained prevalent under the stewardship of
the next Director General, Dr Brundtland (1998–2003), but underneath an
essential shift was already occurring, in the form of a new role for the private
sector. Although the private sector was already seen by governments as an ally
supporting national health development (World Health Assembly, 1993, p. 18), at
this point, it also became an official WHO partner. The words of Dr Brundtland
in 1998 are clear on this point: “We need open and constructive relations with
the private sector and industry” (Buse & Walt, 2000, p. 554). In 2000, she
repeated this statement by emphasizing the impact of this type of collaboration
on the WHO’s ability to expand its scope and influence on global public health
(WHO—Executive Board, 2000, para. 7). The neoliberal context and the severe
budgetary constraints still persisting at the WHO (WHO—Executive Board, 1996, p.
3) encouraged this turn to the private sector.

By 2003, this change of orientation was complete and was promoted by the new
Director General, Dr Lee (2003–2006). “Global health” became the centerpiece of
WHO health policy (WHO, 2003a, see chapter 1). The term “global” permeated WHO
vocabulary, which referred to “global health emergency,” “global health
community,” and “global workforce” (WHO, 2004, 2006). During Dr Lee’s mandate,
the promotion of public–private partnerships gained in importance, which was not
surprising given his prior role in the establishment of “one of the world’s most
successful and dynamic public-private partnerships in health,” the Stop TB
Partnership (2001) (WHO, s. d.-b).

The orientation towards “global health” was supported by the context of
globalization which created an “escalating risk of new and emerging pathogens
and their rapid spread” (WHO, 2018, p. 1). Global threats such as climate
change, air pollution and antimicrobial resistance were also mentioned more
often. In this context, these threats, combined with the emergence and
re-emergence of new infectious diseases gave rise to considerable concern,
particularly within the US administration, which pushed for their
“securitization” (e.g., influenza Abraham, 2011, p. 798). The WHO was obliged to
consider this seriously, given the USA’s position as the world’s leading funder,
and saw an opportunity to expand its health credo to incorporate securitization
as a core element. This new attribute meant greater global attention to health
threats (Abraham, 2011, p. 798) and even made it a priority (Hanrieder, 2020, p.
332). The risk of such an evolution was competition with the United Nations,
whose mandate is the maintenance of international peace and security,
essentially in a context where the UN had already positioned itself as an actor
in health security. To illustrate, such competition was observed in the fight
against HIV (ECOSOC, 1994; UN General Assembly, 2001; UN Security Council, 2000;
Taylor et al., 2014), in particular with the creation of UNAIDS by ECOSOC in
1994 (ECOSOC, 1994). UNAIDS is a Joint Program in the United Nations system with
11 organizations including the WHO. However, as Merson and Inrig pointed out
“UNAIDS distanced itself from WHO, WHO virtually stopped its AIDS program, and
tensions continued to flare between UNAIDS and WHO” (Merson & Inrig, 2018, p.
354). In the global fight against HIV, UNAIDS stood out thanks to its funding
and its ability to build relationships with unusual partners at the domestic
level (NGOs, people, religious communities, and industry) (Merson & Inrig, 2018,
pp. 345–346) which seriously challenged WHO authority.

The concern generated by the issue of health security led to the creation in
2001 of an international partnership called the “Global Health Security
Initiative,” in which the WHO has only observer status. The security vision of
health was later promulgated by the WHO. The WHO decided to update the IHR in
2005 after the SARS outbreak which highlighted the global impact of an
international public health emergency (Whelan, 2008)2. The WHO insisted on
strengthening “epidemiological and laboratory surveillance and … disease control
activities at national level” recognized as “the main defence against the
international spread of communicable diseases” (WHO Secretariat, 2001, 1). This
new version of the IHR enabled the WHO to consolidate its authority and put
surveillance, control, and qualification (e.g., declaration of a public health
emergency of international concern or PHEIC) at the heart of its health credo
during this very challenging period. Finally, without limiting its scope to
specific communicable diseases, the revised IHR became a “key global instrument
for protection against the international spread of disease” (World Health
Assembly, 2005). The incorporation of a “security angle” into the idea of health
strengthened its re-articulation as “global” health by using a vocabulary that
rallies the international community around urgent issues and by promoting
collaboration between the WHO and a wide range of actors (relational
consequences).

Moreover, this period of globalization was also characterized by the recognition
at international level of a multiplicity of players. This led the WHO to modify
some elements of its traditional governance (Dodgson et al., 2009, p. 446),
ultimately impacting its idea of health.

First, relations with the private sector were strengthened and the WHO’s vision
of health was rearticulated. For example, in the context of large-scale
surveillance of infectious diseases (health security angle), the WHO encouraged
the transmission of private and decentralized information, which was facilitated
by new communication technologies. To a certain extent, this helped the WHO
break free from the “constraints of the national veto” in this field (Hanrieder,
2020, p. 336). In addition, the fight against tobacco as a public health concern
was also a key illustration of WHO–private sector relations and of the
organization’s ambition to act globally. Significantly, the Framework Convention
on Tobacco Control (FCTC 2003) was the first international treaty adopted under
Article 19 of the WHO Constitution. The treaty reflected Dr Lee’s global health
approach and it explicitly recognized that “the spread of the tobacco epidemic
is a global problem with serious consequences for public health” (WHO, 2003b
preamble). Moreover, the preventive approach of the WHO’s global health model
persisted through the development of strategies intended to address addictive
substances. Indeed, “in contrast to previous drug control treaties, the WHO FCTC
asserts the importance of demand reduction strategies as well as supply issues”
(WHO, 2003b Foreword). This Convention aimed to “tackle some of the causes of
that epidemic … such as trade liberalization and direct foreign investment,
tobacco advertising, promotion and sponsorship beyond national borders, and
illicit trade in tobacco products” (WHO, 2021, p. 1). The strong involvement of
NGOs (creation of a global network) supported by the WHO, in the elaboration and
implementation of the Convention challenged usual WHO working methods. However,
this change in its methods was considered essential to the success of the
Convention, which called for global governance to manage a global threat such as
tobacco (Dodgson et al., 2009, pp. 453–454). The idea of global health precisely
not only allows this kind of participation by civil society, but also by other,
more controversial, players such as the industry, from tobacco companies here to
pharmaceutical companies in the case of vaccines, for example.

Second, with regard to other international institutions, the WHO’s dependence on
financial agencies continued to grow in the 1990s, leading the organization to
align itself with programs run by these institutions, such as the Stop TB
Partnership. To overcome this type of governance, the WHO developed its own
partnerships with the private sector (global health partnerships) (Ruckert &
Labonté, 2014, pp. 1600–1601). New structural funding possibilities through
collaborations and alliances with other partners enabled the WHO to consolidate
the idea of global health (structural consequences).

Moreover, during this period, health was recognized as a major collective
challenge, assuming an important place in the Millennium Development Goals
(2000) (Boidin, 2015, p. 7). Under Dr Chan’s mandate (2007–2017), the central
position of health on the global agenda was assured (WHO, 2017c, p. 2). The
sustainable development goals (SDGs) (2015), which succeeded the millennium
development goals, recognized the multiple interactions between health and other
levers of development (Boidin, 2015, p. 8). Health was present, to varying
degrees, in all the SDGs (Boidin, 2015, p. 10). A new priority also emerged:
“fairness in access to care as an ethical imperative” (WHO, 2017c, p. 3). These
new collective orientations had an impact on the WHO’s health credo and led the
organization to develop programs aligned with the SDGs such as “The Triple
Billion Targets” (2019–2023) (WHO, 2023). The impact of this context on the
health credo was reflected in efforts devoted to the “One Health” approach,
which consolidated roots established in the early years of the WHO. Indeed, this
approach required reformulating the idea of health to include a cohesive
dimension: an “integrated, unifying approach (which) balances and optimizes the
health of people, animals and the environment” (WHO, 2017b). One repercussion
was the strengthening of inter-organizational collaboration, as illustrated by
the One Health Joint Plan of Action launched in 2022.

The Covid-19 pandemic saw the management of communicable diseases restored to
its position at the heart of the WHO’s health credo in the context of an
emerging global health order, with major programmatic implications. First, there
was a proliferation of structural instruments dedicated to managing the
pandemic, which were partially or fully created by the WHO drawing on previous
experience.3 For instance, the WHO established a “multidisciplinary and
multi-partner technical mission,” mandated to “provide information to the
international community to aid in understanding the situation, its impact, and
effective public health measures to respond to the virus” (WHO, 2020c, p. 4).
Moreover, according to the IHR, 15 meetings of the Emergency Committee were
convened by the WHO Director General. This Committee, composed of experts
appointed by the Director General (WHO, 2005, Article 48), played a central role
in advising the WHO and Member States. The WHO thus promoted the importance of
expertise in health. Moreover, the need for vaccines prompted collaborative
efforts by the GAVI, the Vaccine Alliance, the Coalition for Epidemic
Preparedness Innovations (CEPI), and the WHO to create COVAX as an innovative
platform aimed at “providing innovative and equitable access to Covid-19
diagnostics, treatments and vaccines.” The platform brought together
“governments, global health organizations, manufacturers, scientists, private
sector, civil society and philanthropy” (Gavi, 2020). Finally, another
structural innovation, the Independent Panel for Pandemic Preparedness and
Response, was initiated by the World Health Assembly and the WHO Director
General in order to undertake a “comprehensive review of the international
health response to Covid-19 and … to make recommendations to improve capacities
for the future” (Independent Panel for Pandemic Preparedness and Response, 2021,
p. 8).

Second, faced with a threat to health and well-being that was referred to as the
“21st century’s Chernobyl moment” (Independent Panel for Pandemic Preparedness
and Response, 2021, p. 4), the WHO played new roles that revealed the evolution
of its idea of health. For instance, the WHO supported countries to manage the
“unintended consequences of public health measures implemented to control the
Covid-19 pandemic, including gender-based violence and child neglect” (WHO,
2020b, 2020d). Moreover, the WHO had to counter a major new threat,
misinformation, and the “infodemic,” by developing and disseminating “clear,
tailored messaging on the Covid-19 pandemic and its effects” (WHO, 2020a). The
wide scope of WHO activities in the management of this pandemic was also seen in
its role in negotiating vaccine prices with its COVAX partners (Gavi, 2020).
Moreover, because of the global nature of the health threat and the WHO’s
identification with the idea of global health, the WHO played a “leadership role
in the international system for prevention, preparedness and response to a
global health emergency” (Independent Panel for Pandemic Preparedness and
Response, 2021, p. 48).

As an “extraordinary event that … affect(ed) the health of populations around
the world […] and require[d] a coordinated international response” (WHO, 2022),
the Covid-19 crisis showed that pandemics are global threats by nature and that
“no one is safe, until everyone is safe” (WHO, s. d.-a). The global nature of
the threat supports a global reformulation of the idea of health developed by
the WHO.

The current Director General, Dr Tedros Adhanom Ghebreyesus (since 2017) carried
on the work of his predecessors, with the SDGs remaining the prism through which
the WHO viewed its work and shaped its health credo (WHO, 2017a, p. 3). But he
also focused on consolidating WHO authority, which he considered essential to
building consensus and achieving common goals (WHO, 2017a, p. 5). The issue of
credibility arose in a context of general loss of confidence in international
institutions, and criticism of WHO management of health crises such as Ebola
(2014) and Covid-19 (2020). The need to improve credibility had programmatic
implications. Assessing and improving the impact of the WHO’s work became a
priority. As the Director General pointed out, “[i]t is one thing to write a
plan of action. It is another to put a plan into action” (United Nations, 2022;
WHO, 2017a). Ideas did not appear sufficient to foster and protect the WHO’s
leadership role.

From the 1990s on, the health credo put forth by the WHO became explicitly
“global.” In this third period of evolution, the WHO worked to restore its role
as core institutional player by embedding health goals within the Millenium
Development Goals. WHO and public health no longer stood apart from current
geopolitical dynamics and main loci of influence. There was an attempt during
this period to reinstate the organization within the constellation of main
forces that shape the international order. To do so, there was a need to connect
with new partners like private foundations and to promote a new health ideal,
namely global health. Events and changes during this period had major
programmatic, structural, and relational consequences for the WHO (see
Figure 1). Forced to adapt its mandate and activities to the context of
globalization and emerging health challenges, the WHO recognized that health
crises were becoming increasingly dangerous in terms of their potential scale
and speed of transmission, requiring a strong partnership strategy. The weight
given to the management of communicable diseases in the WHO’s idea of health
thus increased operationally. The third period also highlighted the
reconceptualization of the notion of global threat, which extended beyond
communicable diseases. As the example of tobacco underlined, this
reconceptualization was fertile ground for ambitions initiatives (such as the
drafting of an international convention with programmatic consequences) and new
partnerships that developed and perpetuated a disease-specific approach within
the field of international health (structural consequences). The idea of “global
health” was thus consolidated. Simultaneously, the preventive approach to health
developed by the WHO was re-articulated and grew in scope, strengthening links
between health and development goals. In addition, with the private sector
playing an increasing role and private partnerships gaining prominence through
globalization, the WHO found ways to share responsibility and influence
(relational consequences). Finally, the scale of Covid-19 and the impact it has
had on the WHO and its conception of health foreshadow a coming paradigm shift
and the entry into a new period where climate change is considered a major
global health threat (see for example, the Alliance for Transformative Action on
Climate Change and Health established by the WHO in 2022) (Campbell-Lendrum
et al., 2023).


DISCUSSION

This case study traces the evolution of the idea of a healthy world
population—as set out in the WHO Constitution in 1946—and its robustness through
different phases of the WHO’s development where routine and crisis situations
co-exist. The evolution of the WHO health credo through three main periods
reveals some lessons concerning ideational robustness within the WHO and more
broadly around the role of ideas in institutional development. The foundational
trademark of the WHO rests on the idea put forth in the 1940s of a nascent
international public health order. The journey of this idea stretched through
various cycles of reformulation and re-articulation, with global health taking
form incrementally to recently become its predominant health credo. Adjustments
to the credo have been purposely undertaken by WHO leaders to ensure the
legitimacy of both the ideas and the institution, and support its capacity to
perform critical roles in the contested field of international health. Important
adjustments appear during highly challenging as well as calmer situations or
periods.

During each period of WHO evolution, we found both continuity and change in core
beliefs, causal associations around health and theories on effective approaches
to promote a healthy world population, contributing to and illustrating the
idea’s robustness. The health credo of the WHO is robust in terms of its
pervasive world influence, and in its effectiveness at stabilizing and adapting
the organization in response to crises and political changes. Because the
international and global health field is inherently pluralistic, the
effectiveness of the WHO’s health credo is partial in the sense that it is not
powerful enough to protect the organization from major criticism from time to
time. Ideational robustness does not equate with consensus among all concerned
stakeholders within this international field. Six observations on ideational
work and robustness and on the importance of ideational work in the policy
process can be derived from this study.

First, ideational work is a balancing act where significant shifts in concepts
and theories co-exist with elements of continuity. This underlines the
importance of adopting a processual view on the role of ideas in institutional
dynamics and of not limiting the analysis to the effectiveness of ideas in
periods of high turbulence, a tendency seen in much scholarly work in this area
(Capano & Woo, 2018) that pays little attention to temporal evolution (Howlett,
2019). Ideational work seeks to orchestrate a plurality of views and meanings
and allow the WHO to regain control over sense-making and sense-giving (A. D.
Brown & Humphreys, 2003; Vaara & Rantakari, 2023). The evolution of the health
credo is not based on spontaneous or ad-hoc bricolage, nor does it arise from a
major rupture or paradigmatic shift (Capano & Woo, 2017). Changes to the health
credo are achieved through incremental and cumulative adjustments that
contribute to its legitimacy and robustness during calm as well as turbulent
times. Through these ceaseless adjustments, we can nonetheless identify three
major iterations of the WHO’s health aspirations, from “international public
health” (1948–1968) to “health for all” (1968–1988) to the current dispensation
of “global health.” However, because of the inherent pluralism of international
health, the WHO does not have a monopoly on sense-making and sense-giving in
this field but operates from a unique vantage point as the only institution
within the UN system dedicated to health. Our study shows that while ideational
work seeks to integrate emerging and alternate views, as seen at various phases
in its evolution, it also opens a space where other influential players can
promote their views. The voices of low-income countries in the second period and
the views of private partners in the third period suggest that the WHO is both a
shaper and contributor to ideas that develop outside its own boundaries.
Ideational robustness depends on the organization’s ability to incorporate and
balance a variety of views while also rallying the main trends in international
health.

Second, organizational leaders are well-positioned to perform ideational work.
Some directors general and their teams at the WHO appear more conservative than
transformative in this regard. The ability to adapt ideas to changing contexts
and develop coherent operational changes rests on the agentic capacities of
individuals in influential positions (Howlett et al., 2018). For example, when
she was WHO Director General, Dr Brundtland fully embraced and promoted the
incorporation of private partnerships in joint initiatives as a way to develop
new capacity to face contemporary health challenges. This “global public health”
idea was brought to fruition and officially incorporated in WHO statements under
her successor, Dr Lee. Through ideational work, organizational leaders aim to
regain some control over ideas that circulate within the field of international
health. These efforts have preserved the robustness of the WHO health credo
despite significant political shifts and growing resource limitations. We
suggest that our approach based on institutional work is useful to describe and
understand both the micro-foundations of change in institutions (Harrington,
2015) and the role of ideational robustness in relation to other aspects of
robustness in policy-making, dimensions that have not yet been explicitly
addressed in this emerging body of work.

Third, our case underlines the importance of organizational form in shaping the
destiny and robustness of ideas. Agents perform ideational work in a proximal
organizational context that presents opportunities and limitations. As a
meta-organization of member States (Ahrne et al., 2016) and a design based on
regional organizations (Graham, 2014), the WHO must de facto orchestrate a wide
range of interests, values and priorities to maintain the support and
involvement of member States and integrate the strategic aspirations of its
regional organizations within overarching organizational orientations. In this
context, ideas are a key ingredient both in orchestrating pluralism around some
shared understanding and in muting, at least temporarily, competing views and
voices by gaining predominance in the field, as we saw with the incorporation of
a securitization mindset in the third phase of the WHO’s development. In each
period, the WHO’s health credo plays a dual role of stabilizer and orchestrator
(Uhl-Bien & Marion, 2009) to limit disruptions for an organization that cannot
impose its views and policies by decree. The passage from international public
health to international health solidarity to global health illustrates how ideas
are permeable to the political tensions inherent to this type of organization
and to the prevailing political economy within the field of international
health. Cold War politics and decolonization influence a re-articulation of the
WHO’s health credo toward political neutrality by valuing consensual ideas
around primary care and national health systems. Our research findings support
the notion that ideational robustness is a temporary achievement. Ongoing work
and vigilance by key actors of the organization are critical to constantly
search for robustness in a situation of relative institutional fragility. Works
on robustness have insisted more on the ability of organizations and
institutions to maintain their core functions in turbulent times and much less
on the co-existence of fragility with more robust arrangements (Howlett et al.,
2018).

Fourth, the reframing of ideas observed in the three periods of our case study
has major implications within the WHO as regards operational, relational, or
structural work (Cloutier et al., 2016, see Figure 1). It is in the WHO’s
operations and relational strategies that we see most of the changes that bring
about the health credo’s evolution. Operational work prioritizes certain domains
or incorporates new ones (e.g., primary care) and develops new approaches for
interventions and technical assistance based on changes in predominant causal
beliefs about health. For example, the emphasis on broad health determinants
called for upstream interventions and a departure from programs based on
disease-specific approaches. Ideas gain in robustness when they become embedded
in concrete programs of action that help secure adhesion by a diverse
membership. Attention paid to the diversity of institutional work helps to
understand the process and practices through which ideas materialize in the
real-life context of organizations (Cloutier et al., 2016). Ideational work
seems to have a more minor influence on organizational structure, though the WHO
has faced periods of internal rationalization and has had to adjust its
organizational chart at various times.4 Overall, our study suggests that
ideational robustness is an interdependent phenomenon that takes root in the
capacity of organizations to perform consequential and relevant adjustments to
various dimensions of organizing (Sørensen & Ansell, 2023). This underlines the
importance of studying ideational robustness not in isolation but in conjunction
with other core institutional processes where the agentic capacities of actors
and leaders play a crucial role.

Fifth, while WHO leaders play a critical role in ideational work, ideas are
embedded in the broader materiality and politics of a given organizational field
(Lieberman, 2002). By materiality, we mean both objective situations that emerge
unexpectedly along the way, such as a pandemic (Boin & ‘t Hart, 2022), and the
values and interests of competing or collaborating organizations, including
States (Fligstein, 2005). Ideational work is thus performed under constraints
that reveal both its strategic role and fragility. However, ideas appear to be
granted certain autonomy, recognizing that they are not fully determined by the
material conditions and system of relations that characterize the international
health field. When predominant ideas are at risk of dissonance with evolving
trends and political forces (Cloutier et al., 2016), aspirations may be
jeopardized, as we saw in phase II and phase III of our case study where
reformulation of the health credo to achieve political acceptability had to
contend with the influence of emerging players in international health. The
field of international health is also characterized by a high degree of
complexity where co-existing and potentially competing logics are prevalent
(Greenwood et al., 2011). Institutional logics are broad rationalities that
govern behaviors and aspirations within a given field. A public health logic is
visible from the WHO’s inception, based on the mobilization of knowledge in
epidemiology and communicable diseases to focus on and eradicate a particular
disease. A more comprehensive and socially based representation of health is
fully articulated in the second period and departs from the single-disease
approach. Emphasis is on capacities within the community and the idea benefits
from wide political support from nascent post-colonial nation states and
national health systems. In the third period, an economic logic permeates social
development with the entrée en scène of competing organizations with significant
resources, such as large private foundations. This period brings back some core
attributes of the original public health approach, e.g., the focus on
eradication of particular diseases. These three logics, promoted by political
evolutions and movements at different times, shape the field of international
health and are more or less powerful or enduring. Ideational work and robustness
are a product of this temporal evolution. In each period, the WHO re-articulates
its core ideas around health to respond to and incorporate elements of
predominant logics in the field. The WHO also contributes to shaping predominant
interpretations of these ideational trends as seen in their efforts to promote
primary care as a key lever to improve health across the globe.

Sixth, the WHO as an international institution is analogous to a political
system (Sørensen & Ansell, 2023) as its persistence depends on its ability to
maintain legitimacy despite tensions and competing logics and interests.
Relational work mobilizes ideas to develop and sustain networks of collaborators
or supporters. Ideational robustness becomes a possibility when an idea is
inclusive and agile enough to rally the inherent pluralism of a given field
(Latour, 2007). Ideational work achieves a rational and political reformulation
of the WHO’s health credo to create and recreate alliances in the field. The
WHO’s ability to forge alliances and position itself in emerging networks
appears key to its survival. The co-evolution of ideas and relational strategies
appears crucial for ideational robustness. The growing place of private
partnerships in the third period is a clear example. The ability to perceive key
alliances forged over time to support ideational robustness rests on a
methodology that adopts a processual and longitudinal approach (Reinecke et al.,
2020).

Overall, ideational robustness appears as an effortful endeavour with multiple
ramifications on the organization’s components and activities. Robustness is
constituted by a configuration of elements related to the symbolic and material
substrates of organizations and institutions. Attention to organizational form
is important to grasp the role of proximal context in shaping ideational work
and the destiny of ideas. More distal contextual features like institutional
logics and the political economy of international health send crucial signals to
the WHO and push for more intense engagement in ideational work. While
ideational work is the key ingredient to create ideational robustness, it is
highly contingent on dynamics and forces that inhabit the broader field of
international health and the ability of organizational leaders to perform
various types of institutional work that support the activation and
materialization of ideas.


CONCLUSION

Our analysis suggests that ideational work and the survival of ideas in the
policy process—in this case, health policy at world scale—is driven by agents in
a position to exert influence, by their reading of the environment, and by the
evolving context defined as a set of material and political factors and
conditions. Ideational robustness is produced through a process of reflexive
adaptation by organizational leaders to strategically align health ideals with
context (Howlett & Ramesh, 2023). The WHO has had to constantly revise its
health credo to maintain its position as a predominant and legitimate actor in
international health—an actor that cannot be ignored because of the centrality
of the mission reflected in its health credo. In its quest for ideational
robustness, the WHO has not only adapted to changes and disturbances but has
also contributed to shaping the meanings of trends and novel ideas in the field
(e.g., the notion of “primary health care for all,” which since the 1970s
remains a fundamental issue in global health policies). It is through constant
effort that ideas gain robustness despite changing contexts and the inherent
pluralism of international health. Our analytical approach inspired by studies
on institutional work helps to characterize the recursive relationship between
ideational work and leadership efforts to adapt structure, operations, and
relational strategies.

While the question of robustness has been addressed mainly in the context of
public administration and bureaucracies (Ansell et al., 2023), our analysis of
ideational work and robustness in an international organization underlines the
importance of organizational form in the policy-making process. As a
meta-organization of States and regional organizations, the WHO is highly
dependent on organizational members (Member States) and on its decentralized
components (regional organizations), and faces distinct challenges in achieving
ideational and policy robustness. Attention to organizational forms illuminates
the importance of proximal context in understanding the framing and destiny of
ideas and policies in both disruptive and more routine situations. Our study
also looks at the articulation of ideas with factors found in more distal
context related to crisis, conflict and political ideologies. Ideational
robustness as dynamic adaptation to disruptive events and challenges follows a
cycle of destabilization and re-stabilization through the institutional work
undertaken by organizational leaders. Through this work, WHO leaders orchestrate
emerging positions and views in the field of international health and attempt to
accommodate its inherent pluralism (Vaara & Rantakari, 2023).

Orchestration of meanings by the WHO is performed through a set of mechanisms
labelled as rebalancing, incorporation of new ideas and re-articulation of
existing ideas. The effectiveness of these mechanisms in creating robustness
merits further exploration. For example, the possible decoupling between the
persistence of ideas through time and the realities and dynamics of a given
field appears important. It is plausible that an organization would achieve a
position of strength through the attractiveness of an idea, but at the same time
lose standing in the face of competing organizations and interests.
Organizations may adhere to the idea of global health in general terms, while
simultaneously developing competing or antagonistic strategies that in the end
erode support for the WHO. This risk may increase when the structure of the
organization, in this case a meta-organization, requires internalizing
potentially diverging views and interests, and even more when the organization
finds itself in a situation of resource dependency (Pfeffer & Salancik, 2003).

In line with institutional analysis, ideas appear to have autonomy to shape
organizations, activities, and relations, but are also prefigured and
constrained by the evolving context, including the position, interests, and
values associated with competing logics in the field of international health. By
achieving a certain robustness, core ideas protect the WHO’s position while also
opening a space in which the organization can undertake necessary adaptations
(Vaara & Rantakari, 2023). However, the notion of ideational robustness in
itself suggests that no single organization in a given field has the monopoly on
ideas and on ideational work. The discursive space created by ideational work
can also be mobilized by competing discourses and organizations. In our
analysis, ideational robustness appears to safeguard, however imperfectly, the
position and legitimacy of the organization, and compensate for inherent
resource and political limitations. Other situations may be different. Further
research is needed to understand the relative importance of proximal and distal
context in the determination of ideational robustness and how the level of
contestation and pluralism in a given field influences the destiny of an idea.


FUNDING

This research is supported by a grant from the Social Sciences and Humanities
Research Council of Canada (“Insight Grant” no 435-2020-0470 for a project
entitled “Potentiating the World Health Organization’s normative leadership: an
international study“). Jean-Louis Denis holds the Canada Research Chair on
Health System Design and Adaptation. Catherine Régis holds the Canada Research
Chair in Collaborative Culture in Health Law and Policy and a Canada CIFAR AI
Chair.


CONFLICT OF INTEREST

The authors declare that this manuscript is original and has not been published
elsewhere.

The authors confirm that the manuscript has been read and approved by all named
authors and that the order of authors listed in the manuscript has been approved
by all of them.


FOOTNOTES

1

For example, in addition to its primary mandate to disseminate to Member States
information of general public-health interest related to communicable diseases,
the Office international d’hygiène publique (1907) also worked in fields of food
hygiene, the construction and management of hospitals and school hygiene. The
Health Organization of the League of Nations (1919) was first dedicated not only
to managing the emergency created by epidemics, but also worked on other
subjects like biological standardization, housing, and physical fitness.

2

Mary Whelan explains that this outbreak “led to the realization that an
international public health emergency not only affects human and animal health,
but also economic life and countries’ economic development.”

3

Indeed, as it is written in the Report “COVID-19: make it the last pandemic”
from the the Independent Panel for Pandemic Preparedness and Response, “[s]ince
the 2009 H1N1 influenza pandemic, at least 11 high-level panels and commissions
have made specific recommendations in 16 reports to improve global pandemic
preparedness.”

4

To consult the list of WHO Networks, Committees, Advisory Groups and Taskforces,
see: https://www.who.int/groups.


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AUTHOR NOTES

This paper was submitted to the Special issue proposal of Policy and Society:

Ideational robustness: Robust policy ideas in turbulent times

(Martin B. Carstensen, Eva Sørensen and Jacob Torfing, Roskilde University).

© The Author(s) 2024. Published by Oxford University Press.
This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium,
provided the original work is properly cited.



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