The Centrifugal Reproduction of the World Health Organisation

This paper uses historical institutionalist insights to advance a power-based approach to the design of international organizations (IOs). I argue that path dependence systematically frustrates attempts at intentional design by generating vested interests and formal and informal veto positions within IOs. Initial power advantages are thus hard to cancel out or reverse in subsequent reforms. To the contrary, to ensure the cooperation of vital organizational players, the strategies available to reformers tend to be fragmenting: Reformers can trade organizational power for policy support and thus involuntarily reinforce historical power dynamics (increasing returns to veto power). Or they may circumvent internal blockades through ‘layering,’ i.e. the creation of additional centers of organizational power that further exacerbate fragmentation (layering). Both reproduction mechanisms contribute to a self-reinforcing fragmentation trap. A study of the World Health Organization’s (WHO’s) fragmentation trap substantiates these claims. WHO’s fragmentation is driven, firstly, by an ongoing regionalization dynamic that is the long-term outcome of its founding moment, where the regions enjoyed a first-mover advantage. Ever since, the balance is further tipping in favor of WHO’s six regional units. Secondly, attempts at bypassing the regional veto through extrabudgetary ‘special’ programs have reinforced the fragmentation dynamic. The myriad efforts to reverse WHO’s regional and budgetary disintegration have consistently failed and testify to a highly resilient joint-decision trap that is much deplored, but reinforced reform after reform.