Why the World Health Organisation’s (WHO) funding strategy just isn’t working, and the consequences for public health.
Writer: Katie Dale
Editor: Altay Shaw
Artist: Wenanlan Jin
The Global Health Dream
The WHO is one of the largest United Nations (UN) agencies, a global authority responsible for advancing public health. It has recently come under the spotlight for various failings in its COVID-19 response, but historically the WHO has been at the helm of many global health achievements, including the eradication of smallpox and the Ebola vaccine. The WHO’s budget is shrinking year on year due to problems with the organisation’s funding strategy, and this poses a threat to the autonomy and integrity of the WHO. The funding strategy needs urgent reform, to ensure that the WHO remains the globally respected authority we need in the age of a pandemic.
At present, the WHO is providing life-saving aid in the Yemen humanitarian crisis, leading research into the economic and psychosocial consequences of stillbirths, and coordinating worldwide clinical trials testing existing antiviral drugs in COVID-19 treatment, among hundreds more ongoing projects. This extraordinarily valuable work comes with a price tag, however, that is neither small nor simply remunerated. The WHO is hugely underfunded considering the work it is mandated to tackle, and recent news of the US suspending their contribution to the budget has brought this issue into the public eye. Governments must act to ensure this far-reaching and life-saving work can continue unabated.
Paying the Bills
There are two types of funds contributing to the WHO’s budget: assessed contributions (ACs) and voluntary contributions (VCs). These met a grand total of around $4.4 billion in the 2018-2019 biennium, with less than a quarter consisting of ACs. ACs are payments made by the member states, scaled according to the wealth and population of the country, which the WHO is free to distribute among whichever projects they see fit. In contrast, VCs come with conditions and must be used for the funding of specific programmes of work and/or in specified geographical locations, allowing donors to exert a strong influence on how the money is spent.
Countries may provide VCs on top of the ACs they pay, but large amounts of funding in the form of VCs come from philanthropic organisations, intergovernmental organisations, and crucially private sector donors. There is nothing inherently wrong or unethical about these donations. The Bill and Melinda Gates Foundation was the third largest contributor to the 2018-2019 budget, providing millions of dollars towards vaccine development and saving many lives in the process. The WHO’s guidelines state that donations must be free from any conflict of interest, but this is somewhat subjective, creating a slippery slope towards corruption.
The WHO has become increasingly reliant on these voluntary donations, as the set payments made in the form of ACs have decreased from 46% in 1990 to 21% in 2016-2017. Member states have consistently voted against increasing ACs, reasoning that the WHO needs to improve the efficiency and transparency of its work. Furthermore, there has been a zero nominal growth policy in place since the early 1990s meaning that the value of ACs does not increase with inflation ‒ they are essentially frozen. The deficit has been plugged with VCs, the argument being that earmarking funds for specific programmes of work will increase the WHO’s productivity.
Polluted Politics & Dicey Decisions
The WHO has faced various shortcomings over the past decade, which have entrenched a vicious cycle where organisational failure leads to mistrust by member states, who tighten their purse strings and undermine the WHO as a result. The WHO’s response to the 2014 Ebola outbreak was criticised as being reactive rather than proactive; it took them five months from the first reports of the outbreak to declare a public health emergency in West Africa. However, it seems they did not learn from this, as once again they have come under fire for a delayed emergency response in their management of COVID-19. The WHO declared pandemic status on 11th March, despite cases outside of China having been on the rise since mid-January.
In both cases, the bureaucracy of the organisation and its entanglement with governments have been identified as key factors in the slow responses. Both Ebola and COVID-19 substantially weakened the West African and Chinese economies, respectively, and critics have suggested the WHO acted to protect political and economic interests. Looking back, post nationwide lockdowns in multiple countries and shrinking of the global economy, was it all worth it?
We will never know the true impact of the flawed funding system on the WHO’s failures, however with nearly 80% of the budget coming as earmarked VCs, it is clear that the organisation does not have the freedom or autonomy it needs to make decisions on how the budget is spent. In May 2015, the WHO began structural reform of the emergency response programme, after the poor management of the Ebola outbreak. A Contingency Fund for Emergencies (CFE) was set up, but the WHO was required to raise additional sources of funding for this. The organisation needs more flexibility so that funds can be readily accessed to meet the demands of the environment we live in, to provide the greatest standard of healthcare to the greatest number of people at all times.
A Scandalous History
The increase in VCs has allowed the WHO funding strategy to evolve into a politically and economically biased system, susceptible to private sector lobbying. The two biggest funding nations, the UK and the US, have notoriously capitalist economies, and political lobbying runs rife among their governments. When you examine the way the aviation and transport industries were able to lobby the UK government into backing the Heathrow airport expansion, despite compelling environmental and health concerns from climate campaigners, it doesn’t take too much imagination to see how lobbying from private companies can influence how member states allocate their VCs.
The threats and demands the sugar industry placed on the WHO in 2003 when it proposed a guideline on dietary sugar intake offer a sobering example of lobbying. The Sugar Association, supported by many confectionary and soft drink companies, demanded that the US halt their funding to the WHO unless the guideline was dropped. The WHO was proposing a limit of 10% dietary sugar, and 12 years on when trying to bring in a recommended 5% limit they once again were met with strong opposition from the sugar industry.
America has long opposed many WHO initiatives in favour of supporting transnational corporations which would stand to lose profits. In 2018 they shocked the world by opposing an initiative promoting breastfeeding, threatening Ecuador, the first country planning to introduce the scheme, with trade sanctions and withdrawal of military aid. With the WHO pushing forward initiatives such as the rational use of medicines and ethical criteria for drug marketing, initiatives that could jeopardize the pharmaceutical industry (one of the biggest markets in America), it’s not surprising that President Trump has taken the controversial step in suspending WHO funding.
Towards a Brighter Future
The WHO provides an immensely important global service, and we must protect it from the insular politics that currently grip some of the world’s biggest economies. As increasing numbers of professionals within the scientific and healthcare communities begin to highlight the issues the WHO is facing, the cogs of change are starting to turn. The BRIC nations (Brazil, Russia, India and China) have committed to increasing their ACs to balance the amount of funding coming from VCs, but this alone is not enough. How the WHO will handle being ultimately held hostage by the US, the zero nominal growth policy for ACs, and the ever-present influence from corporate lobbying remains to be seen, and until these issues are resolved, the fate of the WHO as a global health authority hangs in the balance.