A WHO worth fighting for: the case for focused, ambitious reform.

# A WHO worth fighting for: the case for focused, ambitious reform *The Lancet 2026* Comment address the scaffold function of BTK, facilitating protein– 1 Dreyling M, Lenz G, Hoster E, et al. Early consolidation by myeloablative protein interactions and organising signalling complexes.13 radiochemotherapy followed by autologous stem cell transplantation in first remission significantly prolongs progression-free survival in mantle-cell Such a function emphasises the interaction between lymphoma: results of a prospective randomized trial of the European MCL Network. Blood 2005; 105: 2677–84. BTK and BCL2, with promising phase 2 data on the 2 Dreyling M, Doorduijn J, Giné E, et al. Addition of autologous stem-cell combination of BTK and BCL2 inhibitors in combination transplantation to an ibrutinib-containing first-line treatment in patients aged 18–65 years with mantle cell lymphoma (TRIANGLE): 4·5-year follow- with anti-CD20 monoclonal antibodies: zanubrutinib, up of a three-arm, randomised, open-label, phase 3 superiority trial of the European MCL Network. Lancet 2026; 407: 1953–67. venetoclax, and obinutuzumab;14 and acalabrutinib, 3 Dreyling M, Doorduijn J, Giné E, et al. Ibrutinib combined with venetoclax, and rituximab15 in patients with high-risk immunochemotherapy with or without autologous stem-cell transplantation versus immunochemotherapy and autologous stem-cell disease. Whether chemotherapy itself can be replaced transplantation in previously untreated patients with mantle cell lymphoma with multi-agent targeted therapies, and how long they (TRIANGLE): a three-arm, randomised, open-label, phase 3 superiority trial of the European Mantle Cell Lymphoma Network. Lancet 2024; 403: 2293–306. will need to be administered for, requires further study. 4 Wang ML, Jurczak W, Jerkeman M, et al, and the SHINE Investigators. Beyond shoring up a new standard of care for Ibrutinib plus bendamustine and rituximab in untreated mantle-cell lymphoma. N Engl J Med 2022; 386: 2482–94. the initial treatment of mantle cell lymphoma, the 5 Wang M, Salek D, Belada D, et al, and the ECHO Investigators. Acalabrutinib plus bendamustine-rituximab in untreated mantle cell lymphoma. TRIANGLE study itself demonstrates the enduring J Clin Oncol 2025; 43: 2276–84. power of cooperative group research in rare lymphomas. 6 Lewis DJ, Jerkeman M, Sorrell L, et al, and the ENRICH Investigators. Ibrutinib and rituximab versus immunochemotherapy in patients with previously Recruiting hundreds of patients across 14 countries, untreated mantle cell lymphoma (ENRICH): a randomised, open-label, phase TRIANGLE is a springboard for ongoing collaboration 2/3 superiority trial. Lancet 2025; 406: 1953–68. 7 Wang M, Rule S, Zinzani PL, et al. Acalabrutinib in relapsed or refractory beyond the European Mantle Cell Lymphoma Network mantle cell lymphoma (ACE-LY-004): a single-arm, multicentre, phase 2 trial. Lancet 2018; 391: 659–67. consortium. An international triad—a partnership 8 Song Y, Zhou K, Zou D, et al. Treatment of patients with relapsed or refractory of clinician researchers with consumers and industry mantle-cell lymphoma with zanubrutinib, a selective inhibitor of Bruton’s tyrosine kinase. Clin Cancer Res 2020; 26: 4216–24. partners—is needed to iteratively improve outcomes 9 Dreyling M, Goy A, Hess G, et al. Long-term outcomes with ibrutinib treatment across the diverse risk biology of mantle cell lymphoma. for patients with relapsed/refractory mantle cell lymphoma: a pooled analysis of 3 clinical trials with nearly 10 years of follow-up. HemaSphere 2022; 6: e712. Patient-reported outcomes and patient priorities must 10 ASH Clinical News. AbbVie withdraws two accelerated ibrutinib approvals. be integral to study design. Patients with mantle cell 2023. https://ashpublications.org/ashclinicalnews/news/7217/AbbVie- Withdraws-Two-Accelerated-Ibrutinib (accessed March 16, 2026). lymphoma are living so much longer. Patient priorities 11 Zhu S, Gokhale S, Jung J, et al. Multifaceted immunomodulatory effects of and patient-reported outcomes must be integral to the BTK inhibitors ibrutinib and acalabrutinib on different immune cell subsets - beyond B lymphocytes. Front Cell Dev Biol 2021; 9: 727531. study design. As patients with mantle cell lymphoma 12 Wang ML, Jurczak W, Zinzani PL, et al. Pirtobrutinib in covalent Bruton tyrosine kinase inhibitor pretreated mantle-cell lymphoma. J Clin Oncol 2023; live longer, we need them to chart living better. 41: 3988–97. JT reports research funding to her institution from Takeda, BeOne, Roche, and 13 Wang H, Zhou Q, Li L, et al. Bgb-16673, a selective BTK degrader, exhibits Cellectar. JF reports research funding to her institution from Kite Gilead and deeper inhibition of cancer cell signaling pathways and better efficacy in MCL Johnson & Johnson, and speaker fees from Kite Gilead. models. Blood 2024; 144 (suppl 1): 5833. 14 Kumar A, Soumerai J, Abramson JS, et al. Zanubrutinib, obinutuzumab, and *Judith Trotman, Janlyn Falconer venetoclax for first-line treatment of mantle cell lymphoma with a TP53 mutation. Blood 2025; 145: 497–507. judith.trotman@health.nsw.gov.au 15 Hawkes EA, Fletcher R, Wood A, et al. Traverse: a phase 2, open-label, Concord Repatriation General Hospital, University of Sydney, Concord, randomized study of acalabrutinib in combination with venetoclax and NSW 2139, Australia (JT, JF); Australasian Leukaemia Lymphoma Group, rituximab in patients with treatment-naive mantle cell lymphoma. Blood Richmond, VIC, Australia (JT, JF) 2023; 142 (suppl 1): 3054. A WHO worth fighting for: the case for focused, ambitious reform The world needs WHO. This should be an unambiguous debate over legitimate concerns: WHO’s lack of agility, Published Online and uncontroversial statement. But it is not. There are insufficient transparency in key processes and decision April 29, 2026 https://doi.org/10.1016/ signals that WHO’s perceived value has eroded, and that making, and the absence of a clear narrative of the indis- S0140-6736(26)00805-6 its central position in the international system for health pensable benefit the agency provides to the world.1 is under threat. Some critiques of the organisation have WHO urgently needs reforms or risks a decline into been politically natured, but that should not inhibit irrelevance.2 Comment The calls for reforms are not new.3 Yet the imperative proliferation of global and regional actors taking on to act has never been greater and the environment for technical and sometimes normative work, WHO no delivering change rarely more conducive—at a time when longer holds a monopoly as the global authority for the global health ecosystem is shifting.4 Discussions norms and standard setting in health.10 Knowledge about reforms of the international system for health and production is decentralised, with scientific voices of the multilateral system at large are active, partly due to competing in real time. Governments increasingly select the political imperative to navigate the sharp decline in evidence to suit domestic politics. Complicating matters, official development assistance.5 The future of WHO must misinformation and disinformation about health and be a central part of the broader reform efforts.6 This is not science spread at a speed and at scale.11 This situation a question of technical design, but of political choice—and leads to inaccurate positioning of scientific evidence it is WHO member states that must make that choice. and scepticism in some quarters towards health-related The build-up to the 2026 World Health Assembly in organisations. May, 2026, and the forthcoming election of WHO’s next In such an environment, WHO’s continued authority Director-General in May, 2027 are an opportunity to depends on being unimpeachably rigorous, transparent, debate the vision for the organisation.7 and politically insulated. Yet its scientific processes are WHO’s role and function have evolved in parallel with often opaque.12 We recognise that WHO is a political the overall international system for health. There has institution, and its ability to convene governments, been a rapid expansion of actors contributing to health broker agreements, and drive collective action depends improvements during the 21st century.8 But this has led on political legitimacy.13 The challenge is not to remove to a far more complex environment, with organisations politics from WHO, but to prevent political bargaining competing for resources and mandates.9 With the from contaminating scientific judgement. Panel: Six reforms to make WHO ready for the future 1 Refocus on core normative and scientific role 4 Strengthen technical excellence and workforce WHO must prioritise its core functions in setting standards, WHO must improve technical capacity by attracting and developing guidance, and providing scientific leadership. This retaining top talent through transparent recruitment and requires transparent and updated methodologies aligned with stronger performance management. Staff rotation across emerging science and technologies, including responsible use of headquarters and regions should be expanded to distribute AI. WHO must reassert its role in health data and analytics while expertise more effectively, and senior staff should be deployed maintaining a clear separation between political processes and closer to country-level needs. Open and competitive recruitment scientific work. WHO should help to set research priorities and for senior leadership is essential to building credibility and trust. norms but should not conduct research itself. 5 Improve country-level relevance 2 Make governance more effective WHO should tailor country offices to local needs and Governance structures should be streamlined, with the Executive decentralise authority and resources. Country archetypes Board restored to a true executive function. The Framework of should be clearly articulated, such as fragile states, emerging Collaboration with Non-State Actors (FENSA) should be reviewed. capacity, and high capacity. WHO’s role in each country should Introducing a single non-renewable term of around 7 years for the be tailored and regularly reviewed. The goal is to build capacity WHO Director-General and Regional Directors would enhance and systems enabling countries to progress along a path leadership independence and reduce political pressure. towards self-sufficiency. 3 Reduce operational and delivery functions 6 Prioritise financial independence WHO should scale back operational roles, particularly in WHO should continue increasing assessed contributions and emergencies. Functions such as logistics and procurement move towards only non-earmarked negotiated voluntary should transition to agencies better suited for delivery roles, contributions to safeguard independence. Stable financing is such as WFP and UNICEF. This should not be misinterpreted as a essential for maintaining scientific integrity and attracting world- withdrawal from the emergency context. It is a strategic class expertise, while avoiding funding models more suited to refocusing to further strengthen WHO’s authority, coordination, non-governmental organisations. This will take time to fully surveillance, and technical support. WHO should also reconsider materialise but must start now. operational tasks, focusing instead on standards setting and AI=artificial intelligence. WFP=World Food Programme. methodology. 1900 Comment Moreover, over-reliance on conditional voluntary WHO must strengthen its scientific rigour by ensuring contributions from member states, other organisations, its norms, standards, data, and technical guidance are philanthropies, and the private sector distorts WHO’s transparent, timely, and immune to corporate or political priorities. An organisation tasked with independent pressure. It should responsibly embrace technological authority cannot keep relying on fragmented, earmarked innovations, including artificial intelligence. funding.14,15 Institutional independence requires financial Second, surveillance and cross-border threat independence. Assessed contributions from member management. Declaring public health emergencies, states should be the primary source of WHO’s financing; operating early warning systems, and coordinating this process has started16 but should accelerate. global epidemiological intelligence are inherently global WHO was never meant to be a humanitarian logistics functions.15 This calls for investment in global expertise, agency. Yet about 40% of its spending flows through modern data infrastructure, and real-time analytical the World Health Emergencies Programme.17 After capacity. No institution beyond WHO has the mandate the 2014–16 outbreak of Ebola virus disease in west to fulfil these functions. Africa and the COVID-19 pandemic, WHO expanded Third, convening. WHO must remain the arena where into procurement, supply chains, and service delivery governments negotiate health rules, debate priorities, operations. These functions matter, but they are and hold each other accountable.14 Such a political not WHO’s comparative advantage.18 With the 2025 platform is indispensable, but convening power is not Pandemic Agreement WHO now has a mandate to possible without institutional credibility. develop and coordinate a global supply chain network.19 The greatest barrier to these reforms will be political.2 This may sound visionary but risks locking WHO even Member states must now find a shared vision and deeper into operational territory. commitment to deliver reform, which needs to be This expansion in WHO’s role is institutional drift, not combined with bold leadership from the WHO Secretariat. strength. WHO cannot be an all-purpose development The reforms must be accompanied by a cultural shift partner of its member states. When WHO tries to do it all, addressing inflexibility and defensiveness about change. it duplicates existing capacity, weakens its identity, and The reforms we propose about focus and subtraction are invites political backlash when operational realities collide uncomfortable, yet unavoidable. with diplomatic constraints. WHO should coordinate, The choices are stark. WHO must choose stewardship guide, and hold governments to account when they fail to over delivery. Scientific excellence over political accom- report outbreaks or respect international rules. modation. Long-term ambition and impact over short- Each level of the organisation must have a distinct and term visibility. Political weight and technical credibility defined role. WHO’s in-country presence must be strategic are not opposites—they are mutually reinforcing. A WHO and centred on high-level technical advisory capacity whose science is trusted garners political authority when based on the specific needs of countries. Country-level it matters most. The reforms proposed here are designed work should not duplicate that of WHO headquarters and to rebuild that connection, not sever it. regional offices. Equally, the distribution of functions But do governments want a strong, authoritative WHO between headquarters and regional offices must be that is capable of telling them uncomfortable truths? clearly defined: when issues are regional in character, Or do they prefer a sprawling, financially dependent decentralisation is appropriate but it must be matched agency that manages projects but avoids confrontation? with resourcing and accountability. Internal coherence is A more fit for purpose WHO will not emerge by inertia. a prerequisite for external authority. WHO’s leadership, especially the Director-General, are WHO is now at a crossroads. We propose three key hugely influential in shaping the organisation’s direction. functions and six structural reforms (panel) to guide the However, ultimate responsibility rests with the member path ahead. These reforms need to be sequenced over states through the demands they place on WHO and the time, a recognition that change is not immediate, but resources they provide. that the work must start now. In 2035, we believe a reformed WHO would be leaner WHO must strengthen three key functions. First, and more focused, recognised by governments not as norm and standard setting in international health.20 an organisation to be influenced or managed, but as an Comment indispensable authority to turn to. After such reform 5 Organisation for Economic Co-operation and Development. Preliminary official development assistance levels in 2025 detailed summary note. WHO’s scientific guidance will be trusted precisely because 2026. https://one.oecd.org/document/DCD(2026)8/en/pdf (accessed it is independent. Its convening power will carry weight April 22, 2026). 6 Executive Board WHO. Reform of the global health architecture and the because its legitimacy is unquestioned. In a rebalanced UN80 Initiative. World Health Organization. 2026. https://apps.who.int/ global health ecosystem where others deliver, fund, and gb/ebwha/pdf_files/EB158/B158(20)-en.pdf (accessed April 22, 2026). 7 Kazatchkine M, Kickbusch I, Piot P. Leading the World Health Organization: implement, WHO could do what only WHO can: set the challenges & opportunities ahead for a new Director-General. Geneva Health Files. 2026. https://genevahealthfiles.substack.com/p/leading-the- rules, sound the alarm, and bridge the divides. That is an who-challenges-and-opportunities-world-health-organization-geneva- organisation worth fighting for. A failure to build it would director-general-election-global-health-governance-michel-kazatchkine- ilona-kickbusch-peter-piot (accessed April 22, 2026). be a geopolitical failure. 8 Hoffman SJ, Cole CB. Defining the global health system and systematically mapping its network of actors. Global Health 2018; 14: 38. AN is a former Acting and Assistant Director-General of WHO, a former Swedish Ambassador for Health, and a board member of the Alliance for Health Systems 9 Spicer N, Agyepong I, Ottersen T, Jahn A, Ooms G. “It’s far too complicated”: why fragmentation persists in global health. Global Health 2020; 16: 60. and Policy Research. JN is a former Ambassador at Large, US Global AIDS Coordinator, US State Department and former Founding Director of Africa Centres 10 Bharali I, Ogbuoji O, Yamey G. Setting norms and standards in global health: challenges and opportunities. World Bank (working paper). 2025. for Disease Control and Prevention, African Union. PP is a former Executive https://thedocs.worldbank.org/en/doc/84732d9ab04a4578c83e896c124 Director of UNAIDS, has served as consultant to and received an institutional grant b3ff7-0050062025/original/Bharali-etal-Standards-in-Global-Health.pdf from the Gates Foundation, has served as a Special Advisor for the European (accessed April 22, 2026). Commission, is a Co-Chair for the Accra Reset High Level Panel, is a Chair of the 11 Borges Do Nascimento IJ, Beatriz Pizarro A, Almeida J, et al. Infodemics and Strategy Board for the Pasteur Network, is a Chair of PREPARESAB, Singapore, and health misinformation: a systematic review of reviews. is an Independent Director of Biocon Biologics and Biological E. MRCeS is a former Bull World Health Organ 2022; 100: 544–61. Minister of Health for Guinea-Bissau, a former Director of the WHO Regional Office 12 Burda BU, Chambers AR, Johnson JC. Appraisal of guidelines developed by for Africa, and from 2020 to 2025 was Chair and Vice Chair of the Ethics and the World Health Organization. Public Health 2014; 128: 444–74. Governance Committee of the Board of The Global Fund to Fight AIDS, 13 Wenham C, Davies SE. What’s the ideal World Health Organization (WHO)? Tuberculosis and Malaria and alternate member of The Global Fund Board. AA is a Health Econ Policy Law 2023; 18: 329–40. former Regional Director of WHO, former Assistant Director-General of WHO, 14 Kickbusch I, Kazatchkine M, Piot P. Rethinking the role of WHO in a former Minister of Health for Iraq, and a Board member of the Alliance for Health transformed global health order. Geneva Health Files. 2025. https:// Systems and Policy Research. ELM is a former Secretary of Health for Brazil and is genevahealthfiles.substack.com/p/rethinking-role-of-world-health- the Chair of the WHO Advisory Board and Strategic and Technical Advisory Group organization-in-a-transformed-global-health-order-kickbusch-piot-kazatc for Tuberculosis (STAG-TB). RM is a former Assistant Director-General of WHO. hkine?r=31px&triedRedirect=true (accessed April 22, 2026). MK is a former Executive Director of The Global Fund, is a member of the Data and 15 The Independent Panel for Pandemic Preparedness and Response. Safety Monitoring Board of a clinical trial of a tuberculosis vaccine (Biofabri), and COVID-19: make it the last pandemic. 2021. https://theindependentpanel. until May, 2025, was an independent Board Member of Exevir Bio. org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_ final.pdf (accessed April 22, 2026). *Anders Nordström, John Nkengasong, Peter Piot, 16 WHO. Seventy-Fifth World Health Assembly. A75/9. Sustainable financing: Magda Robalo Correia e Silva, Ala Alwan, Ethel L Maciel, report of the Working Group. Report by the Director-General. May 13, 2022. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_9-en.pdf (accessed Ren Minghui, Michel Kazatchkine April 25, 2026). anders.nordstrom.2@ki.se 17 Clark H, Johnson Sirleaf E. No time to gamble: leaders must unite to prevent pandemics. The Independent Panel for Pandemic Preparedness Karolinska Institutet, 171 77 Stockholm, Sweden (AN); Stockholm School of and Response. 2024. https://live-the-independent-panel.pantheonsite.io/ Economics, Stockholm, Sweden (AN); Mastercard Foundation, Toronto, ON, wp-content/uploads/2024/06/The-Independent-Panel_No-time-to- Canada (JN); London School of Hygiene & Tropical Medicine, London, UK (PP); gamble.pdf (accessed April 22, 2026). Institute for Global Health and Development, Bissau, Guinea-Bissau (MRCeS); 18 Pate MA, Kaberuka D, Piot P. Transforming the global health ecosystem: University of Oxford, Oxford, UK (AA); Universidade Federal do Espirito Santo, lessons learned and a vision for the future. Accra Reset Publications. 2026. Vitória, Brazil (ELM); Department of Global Health School of Public Health, Peking https://accrareset.org/publications/Transforming-the-Global-Health- University, Beijing, China (RM); Graduate Institute, Geneva, Switzerland (MK) Ecosystem/ (accessed April 22, 2026). 1 Mohamed Nour M, Kisa S, Kisa A. Examining criticism of WHO’s COVID-19 19 WHO. 78th World Health Assembly. WHO Pandemic Agreement. 2025. response: a scoping review. Humanit Soc Sci Commun 2025; 12: 1198. https://apps.who.int/gb/ebwha/pdf_files/WHA78/A78_R1-en.pdf (accessed April 22, 2026). 2 Tang S, Merson M. Transforming WHO: incremental reform is no longer sufficient. Lancet 2026; published online April 9. https://doi.org/10.1016/ 20 Wellcome Trust. From rethinking to reform: the way forward for the global health system. 2026. https://cms.wellcome.org/sites/default/ S0140-6736(26)00609-4. files/2026-03/from-rethinking-to-reform-the-way-forward-for-the-global- 3 Moser F, Bump JB. Assessing the World Health Organization: what does the health-system.pdf (accessed April 22, 2026). academic debate reveal and is it democratic? Soc Sci Med 2022; 314: 115456. 4 Nordström A, Robalo Correia E Silva M, Clark H, Minghui R, Piot P, Teo YY. Four paradigm shifts to shape an agenda for global health reforms. Lancet 2026; 407: 655–57. 1902 --- [PDF原文](https://sci-net.xyz/storage/7932541/dc0ae4998dabe726a29e9a668850542aa7838fe2f2392eaa9e2983f57e3ec487/A-WHO-worth-fighting-for-the-case-for-focused-ambitious-reform.pdf) DOI: 10.1016/S0140-6736(26)00805-6