The World Health Organization (WHO) is tasked with the ‘attainment by all peoples of the highest possible level of health’, yet, it is widely struggling to meet this mandate, and COVID-19 has revealed significant limitations of the organisation. Despite clear guidance provided by the institution as to how best to respond to the pathogen, many governments departed from WHO's guidance in their response efforts. Is this a new crisis for WHO? Does WHO need to restore its legitimacy in the eyes of the global community? As renewed calls for changes to WHO emerge, in this perspective we lay out the obstacles WHO face to become the WHO ‘we’ need. The assumption is that UN member states need an empowered and well-funded organisation. Yet, many years of discussion of reform of WHO have failed to lead to meaningful change, and glaring challenges remain in its financing, governance and politics, which are considered in turn. The reality may be that we have the WHO that UN member states need – one that can provide guidance and advice, but also take criticism for health governance failures when states want to avoid blame or responsibility. We discuss this, by analysing three key areas of WHO'S challenges: mandate and scope; structure, governance and money and domestic vs international.

The role of the state has been underplayed in scholarship on global health. Taking a historical view, this paper argues that state institutions, practices and ideologies have in fact been crucial to the realisation of contemporary global health governance and to its predecessor regimes. Drawing on state theory, work on governmentality, and Third World approaches to international law, it traces the origins of the ‘health state’ in late colonial developmentalism, which held out the prospect of conditional independence for the subjects of European empires. Progress in health was also a key goal for nationalist governments in the Global South, one which they sought to realise autonomously as part of a New International Economic Order. The defeat of that challenge to the dominance of the Global North in the 1980s led to the rise of ‘global governance’ in health. Far from rendering the state redundant, the latter was realised through the co-option and disciplining of institutions at national level. To that extent, the current order has an unmistakably imperial character, one which undercuts its declared cosmopolitan aspirations, as evidenced in the approach to vaccine distribution and travel bans during the Covid-19 pandemic.

The devastating 2014–16 West African Ebola outbreak challenged the authority of the World Health Organization (WHO) to enforce the legally binding International Health Regulations (IHR) that govern pandemic responses. Under Article 43 of the IHR, states parties can only implement additional health measures beyond the WHO’s recommendations if public health rationales or scientific evidence justify such measures. Yet at least fifty-eight states parties enacted additional health measures, mainly travel restrictions to or from Ebola-affected countries. This article explains why Canada’s visa restrictions targeting Ebola-affected countries failed to meet the IHR’s requirements and therefore violated international law. Specifically, Canada’s response went against public health authorities’ consensus views, the best available scientific evidence on disease transmission, and the WHO’s recommendations. In light of its traditional role as a global health champion, Canada must lead by example and abide by international law, including the IHR, instead of picking and choosing which rules to follow and thereby encouraging other countries to do the same.