Sustainably financing the World Health Organisation, part one

The Executive Board of the World Health Organisation is meeting next week. One of the agenda items is sustainable financing of the Organisation. ‘Sustainable’ in this context refers less to the well-known reality that WHO’s bi-annual budget is minuscule (WHO’s annual budget is less than the University of Texas’ MD Anderson Cancer Centre’s annual budget, less than the Government of Nova Scotia’s health budget, less even than the United States spends on Halloween every year – thanks to corporate front group the UN Foundation for those factoids) and more about flexibility. The discussion centres on increasing the amount of assessed contributions (which are fully flexible) for the WHO’s base segment of its program budget.

The Working Group on Sustainable Financing has shared its report for consideration by the Board, with a headline recommendation that 50% of the base segment of the 2022-23 program budget is financed from member states’ (MS) assessed contributions. The base segment for 2022-23 is $4364m, so an increase of 50% would be $2182m. The rest would be financed from voluntary contributions (VCs).

Note that in the 2020-21 budget, the base segment was financed with $957m of ACs and $2812m of VCs. In other words, about 30%. So the recommendation from the WG is to increase MS’ contribution of ACs to the base by around 20%. Also note that the recommendation is not that from now on 50% of the base segment of the program budget will be funded by ACs. No, it’s not as significant as that. Rather, the recommendation is a welcome (but far less ambitious) attempt to lock in a little bit more ACs for the base. As the WGSF report says: “This absolute figure (US$ 2 182 million) should not change, even if future programme budgets increase further from the 2022–2023 approved budget” (p17). 

The base segment of the budget will presumably increase over the next biennia and, if the WGSF is successful, there will be a little bit more flexibility from the small increase in ACs, but with the additional increase still coming from VCs. Hypothetically, in the future, we could see a flatlining or even decrease in the % ACs as a proportion of the total base segment. But I digress.

The WG assumes that in 2022-23 the base segment will be financed by the same amount of ACs as the 2020-21 budget (i.e. $957m), which will increase incrementally to 50% of the base segment (i.e. $2182m) by 2028-29. The WG tabulates this incremental increase in its Report.

Biennium	Total assessed contributions	Increase
2022-23	956.9	baseline
2024-25	1148.3	20%
2026-27	1550.2	35%
2028-29	2182	40% (sic)

These figures obscure the tiny amount of money involved. How much do these work out per annum, per member state (remember there are 194 of them)? Take a look at the table below:

Biennium	Increase in ACs from baseline of $957m ($m)	Increase per annum ($m)	Increase per Member State per annum (i.e /194) ($m)
2022-23	0	0	0
2025-25	191	95.5	0.5
2026-27	593	297	1.5
2029-29	1225	613	3.14

Yes, that’s right, the WG for ‘sustainable’ financing is asking the member states of the WHO for $613m per year between them; or, if you prefer, $3.14m per year each. That’s not how ACs are calculated, of course (i.e not divided equally between its MS – see UN Resolution A/RES/76/238 for an explanation of the formula), and some MS may pay considerably more/less ACs than others. You can see how much MS pay in this table of ACs for 2022-23. The top three highest AC-paying MS are: US ($207m), China ($115m – China used to be 4th but now it’s moved up into 2nd place) and Japan ($82m). For comparison, many of the SIDS MS pay $9570 over the two years. So, proportionately, the amount of additional funding required of MS will vary considerably below or above the average of $3.14m. I’ve done the sums for all of the MS, but here are a few indicative examples of how much extra low, middle and high income countries would pay:

Member State	Net contributions 2022-23 (US$)	2024-25	2026-27	2028-29	Additional increase	Per year 2022-29
Tuvalu	9,570	11,484	15,503	21,829	12,259	1,532
Ethiopia	95,700	114,840	155,034	218,288	122,588	15,324
Nigeria	2,392,400	2,870,880	3,875,688	5,456,969	3,064,568	383,071
New Zealand	2,784,750	3,341,700	4,511,295	6,351,903	3,567,153	445,894
China	114,883,210	137,859,852	186,110,800	262,044,006	147,160,797	18,395,100

For obvious reasons, the discussion next week won’t be looking at the amount of voluntary contributions member states pay. Because VCs are, well, voluntary, one might argue that MS could just chose to reduce their VCs to cover the cost of their increased ACs. Possibly, although that would require inter-departmental negotiations as ACs most likely would come from MS health budgets with VCs coming from non-health budgets (thanks to CC for that insight). So it wouldn’t be as straightforward as substituting one line of finance with another.

In an earlier draft of this post I argued that the relatively small sums being discussed at the Executive Board illustrated that ‘the issue’ is not the money; that it was nothing to do with the money; and that WHO financing has never been about the money. On reflection (and thanks to DL for this insight), I think that that’s too simplistic. Clearly, for many MS, it really is about the money, and the additional sums this revision of AC contributions implies are not trifles, especially for the lower income countries. No doubt China could easily afford an extra $18m. But behind the sums is a health diplomat who has to make a case for additional funding against competing claims from other (likely more influential) departments. So, while funding of WHO is about power, self-interest and control, it’s also about capacity, priorities and – ultimately – people with limited influence trying to make the best of a difficult situation.

Andrew