The Executive Board of the World Health Organisation is meeting next week. It’s going to be an important meeting and, thanks to the wonder of the internet, you can watch it live from tomorrow. I was invited by the Peoples Health Movement to write a commentary on two documents that will be presented to the Board by the head of WHO’s Secretariat, Dr Tedros. The first is EB148/27: Update on the financing and implementation of the Programme budget 2020–2021, which I wrote about yesterday. The second, and the subject of this blogpost, is EB148/25: Draft Proposed programme budget 2022–2023: Building forward better. It’s an astonishing document, but at 117 pages perhaps one that few people will read. So I’ll try to summarise it as best as I ca… Oh, you just want to know how much the budget is going to be? Sigh, ok: US$6.1bn – just 5% more than the approved budget for 2020-21.
If you want to read all of PHM’s Comments on the various topics under discussion at EB148, you can access them at PHM’s WHO Tracker, coordinated by David Legge. It’s a vital resource and provides a critical commentary on all the major global health challenges facing the word today.
Where to start? How about the title: Building forward better. You see what they did there? It’s clever, if not quite so pleasingly alliterative. But as I wrote in December, ‘building’ is not a great metaphor for our current predicament. Even during lockdown we continue to build ourselves out of existence. Building implies growth at a moment in our history when we can’t just keep growing – a moment when instead we have to de-grow the global economy.
Moving on. I don’t like critiquing the WHO – it feels like punching a wounded animal. But it’s frustrating to read opening statements from the Secretariat that it: “is ready to adapt so that it is fully equipped to support Member States for any eventuality in the future”. Adaptation sums up the approach of WHO leadership over the years to funding from its member states: bending over backwards might be a more physical description. Member States take from WHO but give so little back. They constantly snipe at it from the wings and use it to vent their frustrations and insecurities (ironically). 2020 was bad, but Trump has gone. Perhaps with Biden, the forthcoming World Health Assembly – for which the Executive Board meeting next week will begin to lay the groundwork – will seem less like the global health community’s school playground, where a few bullies stride around with their cowardly acolytes making life difficult for everyone else?
Seizing the Covid moment
The report begins with a conundrum – should it seize the Covid moment and lay out known lessons learned whilst knowing that the Organisation will soon receive recommendations from the Independent Panel’s evaluation of its performance?
Of course, it favours laying out a budget based on what it has experienced thus far in its response to Covid-19. The report is in no doubt where the stress points are: weak country preparedness, WHO’s core capacity to respond to emergencies, and gaps in its workforce. The authors of the proposed budget have a choice as to which health issues they prioritise early on in the report, when they still have the reader’s attention. So it’s telling that these are the three they start with in the report.
The case for health investment
Time and again in this budget the argument is made that it’s much, much less costly to invest in pandemic preparedness than to leave it and pay the costly consequences later of not investing. The report cites the Global Preparedness and Monitoring Board’s annual report A World in Disorder, which estimated the cumulative cost of the pandemic thus far (i.e. less than one year) to be US$11 trillion. Compare that to just US$5 per person per year needed to prevent the pandemic!
There are four key areas of strategic focus for the next biennium:
- Rethink preparedness, readiness and response capacity;
- Build resilience through primary health care-oriented health systems strengthening and the health security nexus;
- Advance WHO’s leadership in science;
- Get back on track with the triple billion targets and the SDGs.
They are the foci that will deliver the 3 pillars of WHO’s 13th General Program of Work: Promote health; keep the world safe; and serve the vulnerable.
By rethinking, WHO means that its member states should not do what they usually do and a) panic in the face of an emergency and b) quickly forget everything once the crisis is over and/or not bother to prepare for the future. It’s tragic that WHO has to spell this out to its members: you have to invest in heath now or you will pay the price later.
Building resilience through primary healthcare, health systems strengthening and the health security nexus?
Another word I don’t like and wish WHO wouldn’t use to frame their report is resilience. If you go for a job interview and they ask you how resilient you are, the correct answers are 1) resilient to what? and b) why the hell are you asking me that?! What kind of employment are you offering here where, in order to do my job, I have to be resilient? Resilience implies an inevitability or permanence of threat. What WHO should be asking is: What is/are the root cause(s) that make/s ‘building resilience’ necessary in the first place? Its focus should be on identifying and mitigating the source rather than conceding that resilience is necessary and then finding ways to strengthen it. Pandemic preparedness is, first and foremost, about prevention.
Getting back on track
WHO concedes that “the world” has fallen behind with its commitment to the ‘triple billion’ target (healthier populations, universal health coverage and protection from health emergencies) enshrined in WHO’s 13th General Program of Work 2019-23. And in order to get back on track ‘the world’ is going to have to fill some pretty significant gaps. And by ‘fill’, the report means more money.
Responding to health emergencies: Five significant gaps
There’s a section in the report – paragraphs 14-18 – which you really need to read if you want to understand why polio is so important. I don’t mean why polio is such a devastating disease; I mean why polio is an important issue with regards to the budget.
- This section of the report – para.14-18 – warrants close reading as it starts to introduce the idea that teams working on polio could be usefully redeployed to create a ‘standing’ (rather than ad hoc or flexible) health emergency response. We are told that during Covid, “teams that had previously specialized in the prevention, detection of and response to poliomyelitis” were performing this standing emergency response (which begs the question: who was preventing, detecting and responding to poliomyelitis if the polio teams were pre-occupied with the emergency response?). However, the ‘gap’ the budget is worried about arises from the fact that the polio teams are going to ‘transition’ to provide broad-based public health capacity. So, who will fill the health emergency service gap they leave behind?
- Gap number 2 – deficits in public health intelligence. WHO wants more money to develop what it is calling a “global data ecosystem” (15) i.e. its digital platform capability.
- “Emergency management”. The wording is very diplomatic but basically this 3rd gap is between WHO ‘incident management’ and ‘national responses’. Interpret this as you will, but it sounds like an indirect reference to member states not doing what WHO advises them to do – as evidenced during the ongoing pandemic. The extra money they are calling for will build the work of the Public Health Emergency Operations Centre Network (para.16)
- Fighting dis and misinformation
- Supply chain and logistics services.
The 2022-23 budget in detail
Paragraph 49 of the budget notes that midway through 2020 the Secretariat undertook a review of its programs and identified “three streams of additional budgetary elements…that suggest an upward trend for this draft Proposed programme budget” (I love the language here – ‘upward trend’ i.e more money required). These three streams are:
- Covid lessons learned;
- Delivering the 13th GPW;
- The polio transition.
We’ll return to these presently. For now, let’s look at the justification for more money. It’s a little hard to follow but the story starts in 2018 with discussion on the investment case for implementing the 13th GPW. In 2018, it was anticipated (see para. 5 of the PBAC document) that the 2020-21 base segment of the budget would have to be US$3944 with an increase of 7.8% (to US$4254) for the 2022-23 budget.
Fast forward to 2020, the world is in the grips of a global pandemic and the EB has identified the three areas listed above for increased investment. For 2022-23 the increase to US$4477.5m is 19% more than 2020-21 (when it was US$3768.7m). In other words, an extra US$709m.
It is not clear (to me at least) where this extra US$709m will come from. Presumably it will be voluntary contributions. But will it come from member states or will non-state actors such as BMGF contribute, perhaps via the WHO Foundation (see below)? I guess we’ll find out soon enough.
The polio transition is a challenge WHO has been working on for a few years now. You can read the relevant EB report and the PHM Comment if you want to get up to speed. The budget introduced polio in para 14 and now, in paragraph 49c, makes the following frank assessment of the polio response: “In the past, because of limited resources, the human resources and operational infrastructure built through the polio programme has been the backbone of the WHO Secretariat’s technical and public health operational support to countries”. Clearly, the polio response was significantly more than just about polio.
There is a worry that it will be much harder to track where the money is going: ”In this draft Proposed programme budget 2022–2023, rather than continuing to combine these functions together under one output, these essential public health functions will be integrated, as appropriate, under different outputs of the programme budget 2022–2023”(para 49).
As money ‘disappears’ from the polio budget line, keeping track of where it has gone will be challenging.
There are the familiar 4 budget segments segments in the 2022-23 proposed budget:
- Base programmes
- Emergency operations and appeals
- Polio eradication segment
- Special programmes segment
Note the following text (para. 51) on segment 2: “Implementation exceeded the approved budget after only the first two quarters of 2020 and is likely to double in 2021. It is therefore proposed to set the level to US$ 1 billion”.
If we recall that in the DGs financing update (EB148/27) that this segment was three times the approved amount, then this figure of US$1bn is surely going to be an under-estimate?
As noted above, the polio segment seems to be drastically under-funded (a 48% drop in budget compared to 2020-21) but this reflects the polio transition, with money re-distributed into the relevant outcomes and outputs of the base budget. The Secretariat concedes that this will be hard to track and is working on making it clearer.
The headline figure
Ok, here we go: The total draft programme budget for 2022-23 is US$6.1bn which is 5% more than the approved budget for 2020-21. Yes, I know – just 5% more than a budget approved pre-pandemic!
Have a look at paragraph 66 of the proposed budget:
“At the Seventy-third World Health Assembly, Member States recognized that not only would adequate funding be required for the response to the COVID-19 pandemic but also that WHO should be provided with sustainable resources, both to respond to health emergencies and to ensure that its core work as the leading international agency in public health is maintained so that critical health needs can be met under any circumstances”.
and then ask yourself how the Secretariat could seriously think that a 5% increase in WHO’s biennial budget for 2022-23 will be adequate to meet the global health demands posed by Covid-19.
Or look at paragraph 2 of the proposed budget and ask yourself whether WHO could possibly be “fully equipped” to respond to the global pandemic on this budget – a mere US$290m more than the 2020-21 budget that was approved before Covid-19.
The WHO Foundation
Still with me? Good, because buried in paragraph 67 of the budget we read about the WHO Foundation. This is what the budget says:
“It aims to attract contributions from high net worth individuals and the private sector in order to supplement the Organization’s resource mobilization efforts, especially for chronically underfunded areas of work and programmes”.
This deserves really close scrutiny and attention. For example, we also learn that:
“Its initial goal is to raise US$ 1 billion over the next three years, of which three quarters is intended to flow directly to WHO for financing the programme budget. The remainder will be provided to finance partners whose work supports the Thirteenth General Programme of Work, 2019–2023”.
Are we going to see foundations like BMGF not just funding disease-specific areas like Polio but now funding WHO programs more broadly, and its funding becoming more integrated into the budget?
The budget document is vast, nuanced and written by staffers who know WHO from the inside. As an outsider with limited access to WHO, I am more than likely misinterpreting many of the figures, failing to understand the implications of much of the detail, and possibly just getting completely the wrong end of the stick. So do keep that in mind and read the draft budget for yourself.
A couple of observations to end with. First, hats off to whoever at WHO wrote this draft budget – 117 pages of dense synthesis of pretty much everything WHO does is no mean feat, and the authors manage to produce a silk purse from what they must sometimes consider a sow’s ear. Second, oh my god, US$290m more than 2020-21! Seriously, you’ve got to be kidding. Third, this from the budget:
“The COVID-19 crisis must mark a turning point. Collectively, the world must take the path of sustained, considered and concerted action now if we are to achieve global health security and avoid the catastrophic impact of global health emergencies in the future”.
Member states: get your wallets out.