Sustainably financing the World Health Organisation, part two

Hold onto your seats folks because the 75th World Health Assembly is about to convene! Health Ministers (and billionaires, CEOs, NGOs, CSOs, etc) of the world converge in Geneva next week to review and approve/contest a bunch of health policies, proposals and budgets. It’s about as exciting as global health gets and, given the multiple crises we’re facing at the moment, definitely worth tuning in for. I was going to continue with my loft conversion this morning, but I’ve been asked to update my January post on sustainably financing the WHO (thanks DL). So here goes…

There are three key documents you need to read. The first is The Programme Budget 2022-23 Proposed revision (EB150/28); the second is Draft resolution: Revision of the Programme budget 2022–2023 (A75/46); and the third is Sustainable financing: report of the Working Group: Report by the Director General (A75/9). I’ll try to work through these as painlessly as possible, starting with the programme budget and then moving to some reflections on sustainable financing.

WHO’s programme budget

WHO’s biennial budget 2022-23 was proposed to member states at last year’s WHA (A74/5 Rev 1), approved and adopted (WHA 74.3). You can read the final, glossy, version here. Table 2 of the budget is reproduced below:

Note the four budget lines (or ‘segments’) because people often confuse the ‘base program’ $4.4bn and the ‘grand total’ $6.1bn. The base is the important segment to keep an eye on, at least if you want to know how much WHO gets to fund all its ‘core’ activities. Table 1 of the budget breaks down the core budget for you.

Obviously, when the proposed budget 2022-23 was being calculated, Covid-19 was raging across the planet and so it was difficult to calculate exactly how much WHO would need to do its job. Various independent reviews of WHO were either starting or were underway, and they would be soon be reporting to WHO with recommendations. So you’ll read in para.4 of the proposed budget 2022-23 a note to say that WHO will hold a mid-term review of the budget and report back to MS at WHA75 with an updated budget for review and approval.

The proposed revision was discussed at WHO’s Executive Board meeting in January 2022. EB 150/28 is the first of my three recommended readings because the document formed the basis for those discussions. Based on the 286 recommendations from 9 independent reviews, this report recommended a revision to the 2022-23 budget of $484.4 million. Let’s say half a billion. That’s essentially how much – two years into a pandemic – WHO reckoned it needed to respond to the pandemic. Hmmm? The document breaks down all the bits and bobs, but most of it ($434.6m) would go to ‘strengthening WHO preparedness for and response to health emergencies’.

Since January, WHO’s Secretariat has had a rethink and made a further revision to what it reckons it now needs. This is where my recommended reading number two comes in – the Draft Resolution A75/46 published last week (13th May). It is proposing to increase its recommended revision to $604m, which would all go to the base budget. That means the base increases from $4.36bn to $4.97bn. The draft resolution presents various ‘options’ in the text, and these will all be up for discussion next week. So that’s where we’re at. In 2020-21, WHO’s base budget was $3.768bn; for 2022-23, if the revisions are approved, it could be looking at $5bn.

Sustainably financing WHO

This is where it gets interesting. The Working Group on Sustainable Financing (WGSF) – lead by the impossibly chisel chinned Mr Bjorn Kummel – met for the 7th and (allegedly) last time at the end of April this year. Here’s a link to all the documents from that meeting. There’s way too much to say about this topic in just one post, so I’ll have to be selective.

Always, always, start with definitions because this is how people with power seek to frame a debate. If you want to fully engage with the question of sustainable financing, you have to be aware of these parameters and critique them. Don’t just accept them. Paragraph 4 of the first WGSF meeting report, back in March 2021, provides its definition of sustainable financing. Sustainable financing is all about predictability, duration, flexibility, independence and focus. There’s nothing in the remit of the WG about ‘need’ (i.e. how much WHO actually needs or should actually have in order to respond to current and future global health crises). In other words, it’s a very technical and limited interpretation of sustainability.

WHO’s budget is always compared with the budgets of other health organisations, and always fares badly in those comparisons – less than the University of Texas’ MD Anderson Cancer Centre; less than the UK’s PHE; less than I spend on socks every year, etc, etc. But it’s not as though the money isn’t there, you know, in the ether. I can’t be the only one pondering the ease with which money is approved in times of war (the US yesterday approved a further tranche of development aid to Ukraine worth 8x the newly proposed biennial base budget of WHO) but hard to come by in times of peace. Is $5bn really, really, all we’re prepared to fund WHO to fulfil its global health responsibilities?

But I digress. Back to the WGSF’s recommendations. I’m going to list these numerically for ease of reference. Quotes are in bold:

1. para 38(a): “the current funding model including the budgeting process for WHO is unsustainable and limits the Organisation’s ability to make an impact where it is most needed…the status quo is unacceptable”. The focus here is on the funding model and process. The problem with the model, as far as the WG is concerned is described thus: “The current WHO financing model results in implementation being largely donor-driven. Commitments to the donors guide how voluntary contributions are implemented and to what end. This approach to funding the Organization leads to discrepancies between the expectations of the Member States as expressed in the approved programme budget, and the de facto capacities of WHO to implement those commitments” (EB/WGSF/1/3). I’m not particularly happy with the way that ‘donors’ (which can include non-state actors as well as MS) and MS are used interchangeably here. But the key problem the WGSF is seeking to address, namely that WHO is dependent on donor’s voluntary contributions (84% of the budget), remains a fundamental weakness of the funding model. Regarding the process, well this is why the WG defines sustainability in the way that it does, because the process is currently unpredictable (on multiple levels).
2. para 38(e): “any increase in Member States’ assessed contributions needs to be accompanied by appropriate governance reforms”. Evoking memories of Hannibal Lecter’s chilling request for prid pro quo, why does there always have to be something for something else? Sure, any International Organisation will always need to review its practices (note that the focus with WHO is always a request from MS that it ‘reform’ – which is a much bigger and politically driven request). But why does this have to be a condition of receiving additional ACs? It’s like WHO is caught in a sadistic, dysfunctional relationship. If WHO had sufficient ACs, allowing it to do all the things it currently can’t do because most of its funding comes from VCs, then perhaps the ‘reforms’ its MS are calling for either wouldn’t be necessary or might be quite different from the ones currently on the table (see para 39(a).
3. para 38(h): “Recognised that initiatives are currently under way to expand funding for the global health architecture, and emphasised the importance of linking these efforts to the critical need to enhance WHO financing”. Yep, this is very important as there is a risk that WHO’s critics will adopt the stock trader mentality (‘in crisis there is opportunity’), roll back on their funding to WHO and invest elsewhere.
4. para 39(b): “that the base segment of the programme budget should be fully flexibly funded”. I discussed this in my previous post but it’s worth re-stating a couple of points. First, this is not a call from the WG for the base budget to be fully funded from ACs. ACs are fully flexible and only come from MS. They currently constitute about 30% of the base budget’s total. Instead, the WG is asking that all VCs to the base budget be “fully unearmarked”.
5. para 39(d)(iv): “explores new, agile and under-utilised sources of funding, such as those from the private sector, in accordance with the Framework of Engagement with Non-State Actors”. The push for WHO to receive additional funding from the private sector is going to gain momentum, I fear. WHO already receives a sizeable amount of financial support from private foundations (BMGF is currently WHO’s second biggest funder, second to Germany). But given Gates’ recent criticism of WHO, plus the polio transition (which Gates bankrolled), one could imagine a WHO with significantly less money from Gates in the future. And how would that shortfall be accommodated? Either way, anyone discussing the sustainable financing of WHO probably needs to brush up on FENSA, toute de suite.
6. para 39(e): “requests the Secretariat to develop budget proposals…for an increase of assessed contributions to contribute to financial sustainability of WHO and with its aspiration to reach a level of 50% of the 2022-2023 base budget by the biennium 2020-31, while aiming to achieve this by the biennium 2028-2029”. Here we go then, the headline act. This is going to take up a lot of column width and generate plenty of hot air over the next week or so. Interestingly, the aspiration reference is new, I think? Previously, the WG was confident about the 2028-29 aim, but in this final report it has introduced a bit of flexibility with that target and given us an additional two years grace time. Are these the first indications of doubt about the feasibility of the 2028-29 target?
7. para 39(e)(ii): “requests the Secretariat to develop a budget proposal with a targeted increase of 20% of the Acs for the biennium 2022-23”. Before I get onto this, here’s a second point worth re-iterating because I’m sure there will be mis-interpretation of this recommendation: the proposed increase in ACs is to reach 50% of the 2022-23 base budget by 2029-29 (or 2030-31). The proposal is not 50% of the total base budget. This is because the base budget is mostly funded by VCs (which will continue to increase) and so will also continue to increase the base regardless of ACs. To return to the 20% increase being proposed here, the WG provides a handy table (reproduced below). The observant amongst you will note that the % of ACs for the 2021-22 budget was about 30% so we won’t see a relative increase until 2026-27. But it’s the absolute amount of ACs that is important (i.e. the increase from $956.9m to $2182m).
8. para 39(f): “that the Health Assembly request the Secretariat to explore the feasibility of a replenishment mechanism to broaden further the financing base”. Another reason to brush up on your FENSA! I really hope that there is space at WHA75 for discussion of this option. Personally, I find it ironic that such a mechanism is being proposed in a document on sustainable financing because replenishments (especially if they are contingent on private sector donations) don’t seem to me to be a particularly safe bet in terms of securing either sustainable or predictable funding. Let me just leave you with Richard Horton’s observation in the Lancet piece linked above: “One final warning. Do not assume that governments will be willing to invest in preparedness, despite the catastrophe we have endured. Countries are already resisting calls to invest in the next replenishment round for the Global Fund to Fight AIDS, Tuberculosis and Malaria”. I would strongly recommend not going down this road of funding WHO via replenishment.

Biennium	Totalled assessed contributions	Increase over current level of assessment	% of base budget 2022-23
2022-2023	956.9	baseline	22%
2024-2025	1148.3	20%	26%
2026-2027	1550.2	35%	36%
2028-2029	2182	40%	50%

Ok, that’s me done. I’m looking forward to following the debates next week. There’s plenty here to push back against, but hats off to the WGSF for the work it’s done – it can’t have been an easy journey to get to this point. Oh, and watch out for Kummel’s chin!

Andrew