Exit, voice and loyalty; how much is the EU really caring about international organisations?

We have chosen to analyse EU-WHO relations through the conceptual lenses of Albert Hirschman’s exit, voice and loyalty framework. It provides a focused yet flexible conceptual framework and thus enables a dynamic analysis of a changing relationship. Moreover, numerous studies across multiple policy fields have proven its analytical value. In the following, we briefly explicate the three concepts, arguing that the beauty of the framework is its parsimonious nature. It is clearly an analytical advantage to keep the concepts separate and thus avoid differentiation into e.g. major, medium and minor exit. Exit means exit. Second, the three options are not equally relevant for our policy field. The reason is that it is exceptionally rare for states to exit international institutions (but there are exceptions). We begin by introducing the original Hirschmanian understandings and subsequently explicate how we will use the terms in the present article.

According to Hirschman, consumers basically have two reasons to consider an exit: if a price develops beyond the acceptable, and when product quality lowers too much. An illustrative example from the TV market: due to a reconfiguration of TV packages, Danish company TDC lost 115.000 customers in a year (Børsen 7 May 2020). The customers felt they did not get the same quality as before and therefore decided to quit the company. In the field of international organizations, states can become members of IOs and they can quit IOs. Indeed, the international multilateral system is full of exit options (Jupille, et al., 2013), including the EU’s exit procedure in Lisbon Treaty article 50. However, exits from IOs are exceptionally rare. Historically, Germany left the League of Nations. Contemporary examples include the US, the UK and Israel leaving UNESCO, Burundi leaving the ICC, North Korea leaving the NPT treaty, the US withdrawing from the Paris Agreement on Climate Change, and the UK leaving the European Union (EU). The partial exit of France from NATO, leaving the military but not the political branch of NATO should also be mentioned because it suggests that exit needs not to be completely either/or.

Not only are exits very rare, they also hardly ever feature in political discourse (Kentikelenis and Voeten 2018). State representatives in IOs seldomly threaten to leave as part of negotiations on a specific position or issue. Such a pattern of behaviour also implies that members of IOs are exceptionally loyal to their organizations. They do not leave and to Hirschman that is loyalty. Moreover, to a rationalist economist such behaviour is very difficult to understand, for which reason he devotes quite some attention to the issue.

Since it is not common for the EU to consider the options of voice and loyalty are more interesting to analyse. Concerning voice, states express concerns, critique etc. According to Hirschman, voice is ‘any attempt at all to change, rather than to escape from, an objectionable state of affairs, whether through individual or collective petition to the management directly in charge, through appeal to higher authority with the intention of forcing a change in management, or through various types of actions and protests, including those that are meant to mobilize public opinion.’ (Hirschman 1970, 30). Hence, voice is the stuff that makes politics, including agenda setting, politicization and alignments. At the UN general Assembly, for instance, state leaders voice concerns about various aspects of the state of UN affairs (Kentikelenis and Voeten 2018). Occasionally, concerns about a given IO morphs into a mandate for a critical review of the IO. In 1998 this happened for instance with the Food and Agricultural Organization (Kissack 2010).

Concerning loyalty, Hirschman includes the term because he is genuinely puzzled about the frequent absences of exit and voice. Customers may be disgruntled about the product quality they experience, skyrocketing prices or the ethics of a producer yet they nonetheless stay loyal to the products or the services. Rational action model would expect the customer to move to a different producer or provider but such assumptions are frequently wrong. The puzzle is so significant and calling for explanation, that an extension to wider everyday meanings seems unwarranted. Thus, it might well be that loyalty has wider meanings, cf. Barry who suggests that “loyalty does not normally mean a mere reluctance to leave a collectivity but rather a positive commitment to further its welfare by working for it, fighting for it and – where one thinks it has gone astray – seeking to change it (Barry (1974: 98).

In the field of international organization, some follow Barry’s conception, ‘Loyalty reflects unambiguous support for or commitment to an institution. This includes calls for countries to better abide by the rules of an institution or efforts to defend an institution’ (Kentikelenis and Voeten 2018, 5). However, we believe that the voice option is fully capable of covering instances where member states demonstrate unambiguous support or stand up for an IO. Loyalty would thus be reserved for instance for explanations that emphasize IOs being political ends and thus not only means to achieve policy objectives; member states that free ride on the collective funding of an IO and members states who are members for symbolic reasons, for instance demonstrating their sovereignty.

Applying exit, voice and loyalty to the EU’s global health positioning before Corona

The EU is generally considered a staunch supporter of multilateral organisations and would not (threaten to) exit an international organisation. However, its presence and positioning is not equally strong in all organisations, and in some, such as the Human Rights Council it is openly critical, in this case about members not adhering to human rights whilst sitting on the Council (Tuominen 2016). Its commitment also varies with regard to funding and diplomatic capacity to engage with the organisation. There are, moreover, differences with regard to how unified the EU is with often the EU member states being the formal members of international organisations and the EU only having observer status. In the UN Security Council, France even has a permanent seat with veto power, whereas other EU member states only join when they are elected for a two-years term. Here, voice and loyalty will be understood as equalling the common position of the EU member states, but the EU may fail to have an outspoken position if they have diverging positions or may in this case even fail to speak with a single voice. The latter could undermine the EU’s voice, even though it could still be strong if individual EU member states are very local and influential.

In the World Health Organisation (WHO), the EU is not a member state organisation, but has observer status as a Regional Economic Integration Organisations (RIO’s), just as in other UN bodies (Battams, van Schaik, and van de Pas 2014). The 27 EU states are amongst the 194 member states of the WHO. The World Health Assembly (WHA) composed of representatives from all these states, serves as the agency’s supreme decision-making body. The main functions of the WHA are to determine the policies of the organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The WHA is held annually in Geneva, Switzerland.¹ Within the WHA normally, it is the rotating EU presidency member state, who speaks on behalf of the EU and its member states often being seconded and sometimes replaced by a representative of the EU (delegation). Within the WHO’s Executive Board, a 34-member state governance body that provides oversight of the WHO’s programmatic work and finances, prepares the WHA and meets twice, the elected European member states also coordinate the European position.

Coordination among EU member states on WHO matters is prepared by the EU delegation in Geneva (Battams, van Schaik, and van de Pas 2014). It is clearly in the driving seat to produce common EU positions. It is backed by the European Commissions’ Directorate-General for Health and Food Safety (DG SANTE) and the European External Action Service (EEAS). Moreover, the European Commission has been the main funder of WHO’s Universal Health Coverage partnership program, a flagship program that enables social health protection and health systems strengthening worldwide (World Health Organization 2019). Despite these commitments, including an annual meeting between the European Commission, European Parliament and senior leadership of WHO, funding by the EU and its member states focused on other pressing global issues over the period 2015–2020, global health clearly not being among them.

Global health was also simply less of a priority for many European countries, expect perhaps for UK and Germany that also developed national global health strategies. Funding for the WHO for a large part had to come from development cooperation budgets, where health typically did not top the agenda, and EU member states were also not keen for the Commission to fund large global health programmes, as this was considered a topic for national development cooperation. It resulted in global health not featuring high on the European political agenda, except for some pressing and topical issues as Anti-Microbial Resistance and Digital health (Steurs et al. 2018).

The EU Council endorsed a stronger EU role in Global Health in 2010, which aimed at a more coherent, system-based and intersectoral approach to global health challenges. It laid out – for the first time – a common perspective for an EU global health policy (Council of the EU 2010). This EU Global health policy was clear about a stronger WHO role. It ‘calls on EU Member States and the Commission to support an increased leadership of the WHO at global, regional and country level’ and ‘The Council requests Member States to gradually move away from earmarked WHO funding towards funding its general budget.’ (Council of the EU 2010, par.12). Eleven years later, it can be concluded that these policy intentions have not materialised (Bregner et al., 2020; Kickbusch and Franz 2020). Even if the EU’s positioning in WHO has become slightly more coordinated with a larger role for the EU delegation in Geneva in preparing it, member states still essentially continued with their own international health policies, and very often these were not high on national agendas. The Conclusions were, moreover, largely negotiated among representatives from development ministries with little ownership by health ministries.

It is for instance remarkable that the EU role in Global Health of 2010 did not specifically consider health security risks an important driver for a more coherent and coordinated European Global health policy approach. After the Ebola viral disease outbreak in West-Africa scholars argued for a European Global Health Strategy that focuses much more on international public health threats (Speakman, McKee, and Coker 2017). Other infectious diseases, including Zika, Yellow fever and Dengue viral outbreaks, Anti-Microbial Resistance and several zoonotic diseases equally lead to calls for more global investment in preparedness and response capacity to such risks. The calls resulted inter alia in the review of the International Health Regulations (IHR) of the WHO that govern the preparation for and response to global public health risks such as infectious disease outbreaks. In 2014 only 64 States Parties (out of 194 WHO members) indicated to meet the minimum core capacity standards to respond to public health risks and emergencies, such as laboratory equipment, skilled health personnel, surveillance and early warning systems (World Health Organization 2015). That is, about 2/3 of countries worldwide did not have the core capacity for global health security. The EU and its member states have been rather silent on this matter, apparently not considering it a priority to provide additional funding for IHR implementation to the WHO.

So when the Covid-19 pandemic was declared and Europe plunged into shock and crisis, there was no strongly backed EU strategy on global health in place. Some member states (France, Germany and Sweden) had developed their own global health strategies, but a common approach was lacking. The US-initiated Global Health Security Agenda (GHSA), which aimed to shore up pandemic preparedness from a One Health approach that aims to avoid a spread of diseases from animals to humans, received some backing by several EU member states and – implicitly – the European Commission. It might be that EU member states and the Commission felt at unease, since the initiative was seen as another global health arrangement side-lining the WHO. It includes about 50 countries worldwide, as well as active involvement of commercial, philanthropic and civil society organisations. However, with the Trump government faltering out of many global efforts, the GHSA partnership has not been very effective. So, even if the EU did not at all contemplate leaving the WHO, it was not very vocal. Neither was it backing or funding the GHSA as a vehicle to strengthen the core preparedness and response capacities of developing countries as recommended in WHO’s IHR. Although there was certainly no exit of the EU and its member states from the global health policy domain; its loyalty was formal and its voice has been only lukewarm (Steurs et al. 2018). In the next section we will specifically analyse the EU stance towards the WHO as organisation and its reform, before looking at how Covid-19 altered the EU’s stance.

The EU’s neglect of WHO reform

While the EU has relatively neglected global health as a policy priority pre-Covid 19, it might be worthwhile to briefly recap which developments took place at the WHO over the last decade. It is relevant to examine to what extent the EU and its member states were instrumental to such a change. Despite attempts to reform the WHO in recent years, the last two decades saw a gradual weakening of the organisation because of its core funding composed of assessed contributions proportionally going down (Reddy, Mazhar, and Lencucha 2018). A plethora of donors got a hold over the organisation by funding specific aspects of WHO’s work(Sridhar and Woods 2013).

A freeze of the assessed contributions was effectuated on the initiative of the US who criticised the WHO during the 1980s because of its stance on breast feeding. The US was also critical about the Essential Medicine List of the WHO medicine department and a decade later allegedly it was also influenced by discontent of the sugar lobby about the WHO being too critical about sugar intake (Birn et al., 2017). Other countries of the Western bloc, including EU member states, followed and since then their fixed contributions are no longer subject to inflation-inferred increases. The current budget of the WHO is for instance equally big as a regional hospital in a Western country; about 5 billion Euros for 2 years; and this is really not enough to cover all the tasks asked for by the members.

The funding base of the WHO being eroded also meant its governance bodies, the WHA and EB, having less of a say in actually guiding programming of the organisation, thereby undermining democratic legitimacy (Van de Pas and van Schaik 2014). In WHO reform efforts, the EU focused at streamlining accountability processes of the organisation, but it failed to spell out what according to the EU should be its core business (Van Schaik and Battams 2014). It also failed to reform a remarkable feature of the organisation, which is its decentralised structure with regional offices with an own mandate and elected Director. According to some, this regional structure is one of the strengths of the organisation since it allows the organisation to work in countries and take account of specific contexts. That may be the case, but the 2014–2015 Ebola outbreak in West-Africa illustrated also the malfunctioning of the African regional office, and the structure undermines clear lines of authority and risks duplication of efforts (Gostin 2015). The European region is considered above all an agency to support former Soviet Union countries with their health challenges and receives funding for this from the EU’s neighbourhood programme. However, the WHO EURO office is also supposed to help EU countries and in doing so its activities overlap with these of the EU’s DG SANTE, the EU agency for disease control ECDC and OECD.

A recent example is the announcement of a Pan-European commission on health and sustainable development by WHO EURO office in August 2020. This commission will rethink policy priorities in light of the pandemic (World Health Organization regional office for Europe 2020). Such a commission, including experts and former ministers, is the default response taken to a new health crisis. A similar policy reflection by WHO EURO took place in relation to the economic crisis from 2008–2013 (Thomson et al. 2015). As the article by Brooks and Geyer in this special issues indicates, there has been a tendency to revert to techno-rational decision making on European health policy matters (Brooks and Greyer 2020). The same is the case for the WHO, and the regional offices of the organisation are used to conduct such a policy exercise (Hoffman and Røttingen 2014). For the EU, it can be questioned what the added value of WHO EURO is, and if it is helpful for health to be treated in such a technocratic way in the post-Covid-19 recovery phase. Nevertheless, an explicit position on this issue or considering an EU exit from WHO EURO, has not been called for.

The EU and its member states have been weak in setting and funding clear priorities for the WHO in the years before Covid-19, one of the key features of using the voice option. But the EU has remained loyal to the organisation. On the one hand it is considering the WHO to be primarily a UN agency to assist poorer countries by supporting them in addressing their health policy challenges and provide humanitarian medical aid during emergencies. On the other hand it has recognised the norm-setting function of the WHO with regard to global health challenges, including on setting norms for pandemic preparedness and response.

Despite its loyalty to the organisation, the EU has not treated the WHO and its regional EURO office as one of the organisations from which it receives advice that may be relevant for its own health policies. So, even concerning the norm-setting function, the EU member states are not paying high respect to it in their own policies, something which became very visible during the pandemic. Several EU countries, for instance, did not take on WHO advice regarding the need to scale up testing, the use of face masks or physical distancing policies.

The EU’s political neglect of the WHO also became apparent with regard to who leads the organization. It was accepted that the WHO would have a Chinese Director, Margaret Chan (2016–2017), with dual citizenship from Hong Kong and Canada, and subsequently a Director (Tedros Adhanom Ghebreyesus, 2017) that clearly was supported by China. So, despite China not contributing much funding to the WHO, its political influence, stemming from its economic and trade links with many low- and middle income countries, has become more visible over time. Through its ‘Belt and Road Initiative’ it invests in health care infrastructure and the production of medicines and vaccines in third countries by state-owned Chinese manufacturing companies (Tang et al. 2017). Only with the Covid-19 pandemic, this has become an issue of concern for issues where the EU’s dependency on China became evident, such as masks and respirators. European media have also reported on the WHO’s initial handling of the Covid-19 outbreak by China that was heavily criticised by the Trump Administration.

In the past two decades also other, non-governmental, stakeholders increased their grip, such as the Bill and Melinda Gates Foundation and the Welcome Trust. Whereas the EU was open to engage these actors more in the official governance bodies of the WHO, China and other developing countries were more critical about non-state actors (NSA) engagement, also because of the link with Western pharmaceutical companies then potentially becoming more blurred, since some foundations are linked to these firms. Despite the WHA having adopted a framework on the engagement of NSAs, their influence and formal role remain contested (Buse and Hawkes 2016), albeit they do fund about 30% of WHO activities (Reddy, Mazhar, and Lencucha 2018).

The EU, and other countries of the West, including the US, could therefore indeed be lamented for not backing the WHO. Small steps were taken to improve procedures for accountability, and the IHR were reviewed after the Ebola outbreak, including the creation of a contingency emergency funding. But the organisation as such was not supported and its leadership and engagement with non-state stakeholders did not receive the attention they would have deserved. In the next section, we analyse if the lack of support of the EU to the WHO in terms of voice has changed, and what it means that the WHO has now clearly turned into a power political battleground that can no longer be ignored. In line with other articles in this special issue we specifically focus at the EU’s ability to adapt to the new circumstances and the degree to which politicisation found expression in loyalty or voice.

Coronacrisis and the US exit from the WHO: A wake-up call for the EU?

When the US President started to accuse the WHO of being too complacent to China about its initial handling of the Covid-19 outbreak, the EU was quick to respond. As with other examples, such as the US pulling out of the Paris Agreement on Climate Change, the nuclear deal with Iran, UNESCO and longer ago the International Criminal Court and Kyoto Protocol, the EU was quick to choose voice, specifically to defend the multilateral approach. Multilateral cooperation resembles the EU’s own construction, which may explain not only the EU’s loyalty to the organisation in times of crisis, but also its voice. Advocating for a multilateral approach to address cross-border issues (such as a pandemic!) is also an issue receiving much support by EU citizens and policy makers, who put a relatively high degree of authority to the UN, which is different from their US counterparts (PEW Research 2011).

According to President Trump, ‘The WHO pushed China’s misinformation about the virus’ and he accused the organization of ‘severely mismanaging and covering up’ its spread (Washington Post, 15 April 2020). After a letter was delivered to the WHO and made public by a tweet, a Chinese spokesperson argued that the ‘unilateral U.S. move to stop funding is a violation of its own international obligations’. According to him, ‘supporting the WHO is upholding multilateralism and supporting international anti-pandemic cooperation to save lives.’ (Washington Post, 19 May 2020). The lack of trust in how China handled the outbreak in its initial followed earlier experiences with the SARS epidemic, where information was withheld (Fidler 2004). Also the death of the doctor who reported the virus in Wuhan in its early phases and was attacked for doing so by the Chinese authorities was covered widely in the US.

EU member states such as Germany and France were trying, behind the scenes, to come to an agreement with the US on a fundamental overhaul of the WHO in order to keep the US on board. However, after the US in June 2020 announced its formal withdrawal from the WHO, these talks came to an end. Publicly, EU leaders condemned the US stance. According to von der Leyen and EU High Representative Borrell (2020), ‘Global cooperation and solidarity through multilateral efforts are the only effective and viable avenues’ and the ‘WHO needs to continue being able to lead the international response to pandemics, current and future’. They ‘urge the US to reconsider its announced decision’. Leaders of EU member states equally stated their disapproval of the US exit of the WHO. German Foreign Minister Heiko Maas said the US funding freeze amounted to ‘throwing the pilot out of the plane in mid-flight.’ He described the WHO as the ‘backbone of the fight against the pandemic.’ (DW, 2020). Also Chancellor Merkel and French President Macron expressed their support for the WHO during the WHA of May 2020. This indicates that the EU has opted to voice is political support for the organisation during the pandemic.

Germany stepped in to cover the financial gap that the US has left by pledging an unprecedented € 500 million to the WHO for 2020. France has committed an additional € 50 million to WHO as well as a € 90 million commitment to a new WHO Academy. The EU pledging conferences (see below) have also been an example of ‘fast multilateralism’, in this case targeting vaccine, therapeutics and diagnostics development for Covid-19. Time will tell what this implies for a more structural investment in the WHO and global health multilateralism.

The EU led the development of the main resolution of the virtual 73th WHA in May 2020 that focused exclusively on the response to the Covid-19 outbreak.² This resolution has as main features the request for a UN broad response; call to countries to respect the IHR; a call to international organisations to create a voluntary patent pool for the development of a Covid-19 vaccine; the request to WHO to establish an impartial, independent and comprehensive review of the coordinated international health response to Covid-19. EU leadership has ensured broad multilateral support for this resolution, including from China. A Covid-19 technology access pool should become the executive arm of this resolution, ideally designed after the UNITAID-established and supported Medicines Patent Pool.³

The devil will be in the detail, because it is required that also Trade-Related Intellectual Property Rights (TRIPS) flexibilities will be respected by the EU and its member states, also the one with pharmaceutical industry pushing for patents protection. The global governance of intellectual property rights has been, and will be, of crucial importance in relation to public access to medicines, vaccines and medical diagnostics. This discussion does not take place in the WHO but in the World Trade Organization (WTO) TRIPS council, where South Africa has recently pushed for a resolution that wants to simplify the TRIPS flexibilities requirements, including for compulsory licensing, with the aim to protect public health and secure access to essential technologies. However, pharma producing countries, including from the EU, are of the opinion that the current system, based on voluntary licensing suffices (Pitnaik 2020). Indirectly, this could be considered to undermine the WHO’s efforts to quickly and at low cost make a Covid-19 vaccine available.

On the basis of the WHA resolution, the WHO established an Independent panel for Pandemic Preparedness and Response (IPPR) that should evaluate the Covid-19 – response. This EU-backed initiative can potentially also defuse some of the geopolitical tensions around the global governance of the Covid-19 pandemic. The IPPR was launched in July 2020 and is co-chaired by former Prime Minister of New Zealand Helen Clark and former President of Liberia Ellen Johnson Sirleaf.

France and Germany moreover chose voice and presented a non-paper on WHO reform in general, its work in health emergencies and its IHR work.⁴ The paper, that was presented after talks with the US on WHO reform were ended and that is linked to G7 talks among Health Ministers, mentions that Covid-19 has to be used as an opportunity to strengthen the abilities of the WHO to fully act as the leading and coordinating authority in global health. It favours a long-term strengthening of WHO and makes specific proposals to strengthen its role and responsibilities in pandemic preparedness and response. The paper explicitly acknowledges the insufficiency of the funding currently provided to the WHO and calls for an increase of the assessed contributions. It calls for WHO mandated international experts to independently investigate and assess (potential) outbreaks of infectious diseases as early as possible. This is revolutionary since currently other countries will only be informed when authorities of a country have acknowledged the outbreak of an infectious disease. Under the IHR the WHO can be notified by doctors or other experts, but first has to consult the official focal point of a country and await its reply. This makes it easier for countries to conceal outbreaks and is a potential cause of delay in responding to them.

The pandemic, the announced US exit from the WHO, as well as the assertive position of China via its ‘mask diplomacy’ constituted a wake-up call for the EU. It adapted and became far more vocal in the WHO. In Brussels the issue has become chef sache and the EU was successful in getting its resolution adopted at the WHA. Despite the severe economic crisis that erupted due to the pandemic response, member states still stepped up their financial contribution. France and Germany presented plans to reform the WHO and the IHR. Brooks and Geyer have shown clearly in their analysis of the next EU budget negotiations that further ‘Europeanisation’ is not a given (Brooks and Greyer 2020) This may cause political dispute on the EU’s future position and budget support vis-à-vis the WHO. At the time of writing this article a new diplomatic conflict is rapidly emerging where the EU commitment to WHO is put to test, namely the issue of who will have access to a COVID-19 vaccine, when and at what price.

The vaccine race as test case for the EU’s commitment to the WHO

The magnitude and severe impacts of the pandemic have resulted in strong calls for action with many considering a vaccine the only way to halt the disease. Pressure on politicians to enable the development of such a vaccine is enormous. In May 2020 the European Commission presented its vaccine strategy that centred on joint EU purchasing and distribution of vaccines (European Commission 2020). Through the Emergency Support Instrument deals can be made by the EU with vaccine developers. Funding is provided for the development, trials and production with EU member states being able to buy the vaccines when they are available. The US, Russia and China are undertaking similar efforts in what could be termed a global vaccines race. The question is though how this relates to the EU’s voice in and support of the WHO-backed global efforts on vaccines.

EU coordination on vaccines in itself was contentious. About two weeks before the EU presented its strategy a coalition of four EU members states, France, Germany, Italy and the Netherlands had already signed a first deal with a vaccine developer based in the UK. In August 2020 this deal was taken over by the European Commission, but at first it seemed that EU member states were going it alone in the vaccine race. It is still not clear if they may also be able to be front in row of buying the vaccine and if they accept EU guidance with regard to the distribution of the vaccine (Van Schaik and van de Pas 2020). The European Commission is now in the driving seat to strike good deals, but this is inherently difficult since many vaccines do not prove to be effective, become irrelevant or have several unexpected side effects which only become evident in the trials phase or when already in use. Hence, quite some public money will be wasted, because of the nature of the vaccine research and development business, something the EU can easily be blamed for at a later stage thereby fuelling vaccine hesitancy and possible distrust by the public. This reminds to the case of the Dutch and Swedish governments buying upfront H1N1 flu vaccine dosages from pharmaceutical companies in 2009. In Sweden, the H1N1 vaccination was related to an increase of narcolepsy (Determann et al. 2016). In the Netherlands more than 25 million of H1N1 vaccines dosages remained unused and got wasted because of disputable policy advice to the government by a national expert (Butler 2010).

In addition to organising joint purchasing, the Commission announced to officially back global initiatives to fund vaccine development and production. To this end, the Commission organised in May 2020 and June 2020 pledging conferences to raise funds for the development of vaccines, therapeutics and diagnostics. With support of the WHO, Gavi and other key stakeholders it supported the ‘Access to Covid-19 Tools accelerator’ (ACT-A). This is a Facilitation Council that should guide the key strategic, policy & financial issues in the development of new Covid-19 tools, including the COVAX vaccine that should be available for low- and middle income countries.⁵

However, initiatives of the EU to secure doses of vaccines for their own populations are running against efforts within the COVAX facility to provide affordable vaccines worldwide. A global effort would at least in principle secure equal access to a vaccine and prioritisation of the most vulnerable groups . However, in reality countries who pay more have more access to the vaccines and Russia and the US do not participate in COVAX. For EU member states joining, the question is if they get double access if they join a vaccine development effort sponsored both by the EU and COVAX, and they can only spend their budget once. Hence, an element of competition has emerged with the EU officially supporting a global effort, but in reality being in competition with it. A technical solution is now proposed, akin to the CO2-emission trading market, whereby GAVI and the COVAX facility will facilitate a ‘marketplace’ for trading or selling vaccine doses between countries as to secure participation from high-income countries (Reuters 2020b).

Moreover, the EU will have to position itself when the vaccine race gets a power political edge, which may happen with several of the main contenders already claiming to have a vaccine available that is currently being tested on people. It is not difficult to imagine how being able to share a vaccine with other countries can become a powerful asset in the world of diplomacy and power politics. The EU’s stated ambition to learn the language of geopolitics (Borrell 2020) may therefore mean that the EU, just as the other powers, will prioritise getting its own vaccine in order to use it for its own citizens and support countries it prioritises to help, possibly via the ACT-A and COVAX facility. The European Commission announced late August 2020 that it will join the COVAX facility and will provide a contribution of €400 million in guarantees. China followed quickly. This may imply that the WHO’s facilitated COVAX facility might become the new arena of political dispute and vaccine diplomacy, especially if the pandemics lingers on with only a limited number of effective Covid-19 vaccines available. The dilemma between willing to have a vaccine available quickly for EU citizens and advocating for a global vaccine effort based on solidarity between countries may undermine the EU’s multilateral credentials, and hence it voice in WHO policy circles.

Comparing the EU’s voice in global health multilateralism before and during Covid-19

The vaccine competition between COVAX and the EU’s efforts can be considered a first indication about the EU not truly supporting a global approach to health with the WHO at its centre. Another potential indication are the talks with the US on comprehensive WHO reform, which is an indication that not only the US, but also EU member states Germany and France are critical about the functioning of the WHO. After they halted their talks with the US, they were quick to present their own proposals for WHO reform. This is an example of the EU member states using voice to change the state of WHO affairs.

Indeed, in comparison to the previous decade, the Covid-19 pandemic has catapulted the EU in a far more vocal and united positioning in the WHO. Even though it never considered to exit the WHO and its regional office WHO-EURO, in previous decades it did not take a similarly strong interest in debates on their reform. Some individual member states contributed and a common position was in place, but it contained hardly any radical substance for structural change. The current proposal by Germany and France is more substantial, but also refrains from sharp choices with regard to the main tasks of the WHO, fails to specify a minimum budget for its core tasks and is quiet on its regional structure. Of course the EU cannot impose its views and therefore needs to consult with others for any reform to succeed, but if its own position already is very close to the status quo more than muddling through cannot be expected.

Moreover, even though the exit of the US has been condemned strongly, several EU representatives seem also to be critical about how the WHO treated China. They question why it has not been more demanding in calling for an enquiry about the origins of the Covid-19 outbreak in China. Additionally, efforts to implement the IHR need to be stepped up in a number of countries; and monitoring mechanisms and reporting possibilities need to be reinforced. Germany and France call for WHO experts that are allowed into countries with an independent mandate for investigation, but this can be considered an exceptional breach of state sovereignty and is probably not acceptable to China and other non-democratic countries (or even the US).

It is not clear if the non-paper on WHO reform is also supported by other member states and the EU as such. However in November 2020 new EU Council Conclusions were adopted on the role of the EU in strengthening the World Health Organization (Council of the EU 2020). Clearly, again an announced US exit drove the EU together. The EU becoming more vocal in and committed to multilateral efforts, including climate change and international criminal law, is something witnessed before (Groenleer and Van Schaik 2007). What is different perhaps is that the EU realises that it really needs the WHO during this pandemic in order to obtain information on what is happening in other parts of the world. Since infectious diseases cannot be stopped at national borders, it is clear that a global approach is to be preferred in the view of the EU’s leadership.

A most remarkable step in Europeanisation can be witnessed in the case of vaccine purchasing and distribution, but here it may go to the detriment of the global approach. The EU’s concerns over strategic autonomy motivates this development, as well as a simple desire among EU member states not to become each other’s competitors for buying a vaccine which increases its price. For the European Commission it is risky, since the vaccine race is very politicised and when vaccine investments do not pay out, as may very well happen due to the inherent risks in vaccine development, it can easily be blamed for having wasted public funding, even contributing to distrust and vaccine hesitancy. Europeanisation here is thus clearly happening, but may come back to hunt the EU as (global) health actor if the vaccine does not turn out to be the panacea so many are hoping for. And because the European effort competes somewhat with the global, multilateral, effort it has come to the detriment of commitment to the WHO.

Conclusions

When confronted with crisis and the US withdrawing from a multilateral effort, the EU tends to respond strongly. It seems that US unilateralism pulls the EU together and brings to the fore its core values, among which multilateralism takes an important place. For the EU it is evident that a problem of transboundary character, requires a multilateral effort to address it. However, the EU is not fully committed to the WHO; it is also strengthening its own ability to obtain quickly a vaccine for European citizens, which automatically means less availability for others, and hence a less global approach.

The EU’s voice is furthermore potentially thwarted by EU member states being critical about the current functioning of the WHO. Whereas the EU has been relatively quiet in previous WHO reform rounds and EU member states failed to provide sufficient untied funding to the organisation, the Covid-19 pandemic and US announced exit have prompted Germany and France to propose WHO reform and provide additional funding. It is not clear to what extent EU institutions and other EU member states support these efforts, but Council Conclusions on WHO were recently adopted. And even though it illustrates the EU is critical about the current functioning of the WHO, it also illustrates it is willing to keep it alive, now and in the future.

Future research could focus on how committed the EU will continue to be to uphold the WHO. After the success of the Covid-19 fundraising conference by Commission President von der Leyen and EU-initiated resolution in the WHA, it will be interesting to analyse if EU coordination in the WHO will be more structural and if representatives of health ministries of EU member states will start to consider health, and its international dimension, more of a European affair. With Brexit, the potential for a more Europeanised external action, also in fields traditionally not being much Europeanized, is now present. The question is if the EU institutions dare to occupy the space, have the capacity to do so and are allowed in by the EU member states. This would facilitate the EU to truly become not only loyal but also vocal and thus push for an effective WHO.