The 152nd meeting of WHO’s Executive Board is likely to be one of the most important in recent years. From a financing point of view, the Board will be considering a Report of the Agile Member States Task Group Strengthening WHO’s Budgetary, Programmatic and Financing Governance (EB152/33), a report from the Director General Matters emanating from the Working Group on Sustainable Financing (EB152/34), and – and this is why the discussions will be so significant – a report from the Director General Sustainable financing: feasibility of a replenishment mechanism, including options for consideration (EB152/35). It’s looking quite likely that WHO will, in the future, be funded in part through a replenishment mechanism – the first time in its history. It’s early days, and we will know more once the EB has discussed the documents linked above, but I’d like to spend a bit of time in this post thinking through the implications of such a mechanism.
We knew this was coming. You’ll recall that in May 2022, the Working Group on Sustainable Financing (WGSF) delivered its final report to member states at the World Health Assembly. Sustainable financing: report of the Working Group (A75/9) is an important document because it provided a suite of recommendations that will shape the future of WHO funding. Paragraph 39(f) recommends: “that the Health Assembly request the Secretariat to explore the feasibility of a replenishment mechanism to broaden further the financing base, in consultation with Member States and taking into consideration the Framework of Engagement with Non-State Actors”. EB152/35 is WHO Secretariat’s summary of that exploration. The Secretariat did 3 things: 1. It “reviewed the feasibility of a WHO replenishment mechanism in line with the principles set out by the Working Group on Sustainable Financing”; 2. “It consulted with Member States through the work of the Agile Member States Task Group”; and 3. it “benchmarked a set of replenishment mechanisms within and beyond the global health arena”. I’ll get to this report later in this post, but first I want to go back a step and summarise how we got to this position.
To do that, you have to review the documentation provided by WGSF during its seven meetings held between March 2021 and April 2022. In these documents you can trace the evolution of the idea of the replenishment mechanism. Box 1 below provides you with specific references from these documents for every significant mention of the mechanism (you’re welcome).
|WGSF 1/5 para 14|
WGSF 2/6 paras 6 and 13
WGSF 3/3 paras 2, 7, 11, 14, 15, 18, 19 and 27
WGSF 4/3 paras 11, 12 and 16
WGSF 5/3 paras 22, 24, 26, 28-30, 36 and 39
WGSF 5/4 para 15
It’s not until the WGSF’s 2nd meeting (in April 2021) that its members start to introduce the idea of a replenishment mechanism. Both Gavi and the Global Fund recounted their own experiences of replenishments, but there was no consensus from member states as to whether such a replenishment mechanism could apply to WHO. Why not? Well, the work of WHO is much broader than the narrow focus of the two partnership; the partnerships are able to achieve impact in a shorter period of time, meaning that their results are more tangible (NB: this is all possible because of the mandate of the partnerships, which is significantly narrower than the WHO mandate); donors to the partnerships have much more say over how their money is spent (because of the narrower mandate and because of their governance structure, which is less complicated than WHO’s). Nevertheless, some member states still expressed an interest in exploring a replenishment model for WHO (though some did not).
Discussions on the replenishment mechanism ratcheted up a gear at the WGSF’s 3rd meeting (in June 2021) with eight paragraphs devoted of its meeting report devoted to the issue. Interestingly, the meeting referred to one of the recommendations of the Final Report of the Independent Panel for Pandemic Preparedness and Response (IPPPR) (published in May 2021) which is worth quoting in full: “Establish WHO´s financial independence, based on fully unearmarked resources, increase Member States fees to 2/3 of the budget for the WHO base programme and have an organized replenishment process for the remainder of the budget” (p49). You might wonder why the IPPPR was so keen on recommending a replenishment? Easy answer – both Mark Dybul (previous head of the Global Fund) and Michel Kazatchkine (previous head of the Global Fund) were panel members.
Members of the WGSF talked up the positive experiences of Gavi and the Global Fund’s replenishments (perhaps forgetting that in their first meeting a Gavi representative had described the problems the partnership had had with replenishments during its first ten years). A few member states expressed some reservations (would some key donors be turned off or even lost completely by such a mechanism), but the meeting report notes that “there was broad consensus that the replenishment model should be explored further in combination with increasing AC core funding, noting that replenishments would need to be focused and linked back to results”. The WGSF meetings have a ‘step-wise’ decision making process, meaning that in order to proceed, certain steps have to be articulated and agreed. And so it was that the Chair simply asked the members a question: did they agree “to explore the replenishment model as a type of funding mechanism (that would include Member States and non-State actors) to cover the remaining portion of the base programme budget”. They did.
People may ask in the future how the Organisation ever got to have a replenishment mechanism. Well, IMO June 2021 at meeting 3 of the WGSF is the moment when the die was cast, and I would argue that the answer is a combination of three things: a decision-making process that made it possible to make certain decisions without the proper consultation (criticism of the replenishment model is particularly notable by its absence, for example), a pandemic report published a few weeks earlier that had a convenient recommendation, and a staged intervention by someone invited to the meeting who wanted that recommendation to fly.
Between meeting 3 and meeting 4, members of the WGSF undertook “informal consultations with Member State donors and foundations as well as with representatives of GAVI, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank on a replenishment model”. Member states were briefed about these meetings but, reading the notes, it looks like meeting 4 stalled. Member states reiterated concerns raised earlier about why they were drawing comparisons of a replenishment model from actors with quite different governance structures and mandates. So the WGSF went away to see if anything could be ‘tailored’ to meet WHO’s needs.
The notes from meeting 5 (December 2021) are interesting to read if you want to learn about the origins of the “pragmatic” and “incremental” increases in assessed contributions to the base budget that was eventually approved at the WHA in May 2022. You can read in the notes concerns from member states about the “severe financial constraints” they were facing as a consequence of the pandemic (the actual sums eventually proposed were minuscule, but let’s not get into that now). The notes don’t go into any detail, unfortunately and it is a shame that the meetings weren’t recorded. Instead, all we get is this summary: “Members supported proposals made by the Working Group for full funding of the base segment of the programme budget with assessed contributions, increasing Member States’ assessed contributions to at least 50% of the budget and introducing a replenishment mechanism to cover the remaining 50%”.
It does look, however, that while some Member States were in favour of exploring the option of a replenishment model, “others did not consider such a model appropriate for WHO and favoured strengthening existing financing structures before contemplating the creation of new ones”. Furthermore, even if a replenishment model were agreed in principle, “the need to assess carefully which elements of WHO’s work would be supported with this funding” would be necessary, and “financing from categories of contributors other than Member States would require particular attention”. This latter point is why you will see future discussion of the replenishment model repeatedly linked to the Framework for Engagement with Non-State Actors (FENSA). Nevertheless, a majority of member states who completed a five-question survey sent to them by the WGSF supported the IPPPR recommendation of a replenishment model to cover whatever funds to the base segment were not provided by ACs. Meeting 5 began to formulate the key recommendations that were further developed at meeting 7 (April 2022) and eventually approved at the WHA in May 2022:
The replenishment mechanism, with relevant rules of procedure, would be based on the following principles: (i) is Member State-driven and approved by the Health Assembly and open to all donors that comply with the Framework of Engagement with Non-State Actors; (ii) addresses both WHO needs for flexibility and donor needs to show accountability for results to their own constituents; (iii) ensures efficiency and no competition between different parts of WHO; (iv) aligns with the defined needs of WHO as approved by its governing bodies and is oriented to prioritize the financing needs of the base budget in all its components; (v) aligns with the global health architecture avoiding competition with other global actors; (vi) aligns with resolutions and decisions of the Health Assembly.Seventh meeting of WGSG Geneva, 25-27 April EB/WGSF/7/4. Para 39(f)
Ok, so we now have a clearer picture of why a replenishment mechanism is being considered at EB152 next week. Let’s now turn to the feasibility report put together by WHO’s Secretariat (EB152/35)? It focuses on the key principles noted above and tries to reassure the Board that, yes, a replenishment mechanism is feasible. Regarding principle 1 (that the mechanism be open to all donors) the report kicks off with an un-sourced and bold claim. Apologies, but I’m going to have to quote para 6 in full:
Multisectoral replenishment approaches are traditionally the most promising way of ensuring a successful replenishment campaign. This requires the replenishing organization to engage with nongovernmental organizations, private-sector entities, philanthropic foundations and academic institutions, as well as with sovereign donors. However, during a WHO replenishment campaign, all activities relating to non-State actors would continue to comply with the principles and procedures of the Framework of Engagement with Non-State Actors.1 As such, WHO’s work would continue to be protected from potential risks, such as conflicts of interest and undue influence.Para 6 of EB152/35: Sustainable financing: Feasibility of a replenishment mechanism
The ‘argument for traditionality’ is a curious argument for the secretariat to lead with. You might be surprised to learn that WHO has had a replenishment mechanism since its creation 75 years ago. Its funds are replenished every year by its member states’ assessed contributions (ACs), which are calculated against clear and transparent criteria, are predictable, and are completely un-earmarked. Best of all, the Secretariat doesn’t have to do any of the leg work required of a multisectoral replenishment because the replenishments are pretty much automatic. So, if we’re looking for ‘traditional’ mechanisms, look no further than WHO’s model of assessed contributions.
Of course, it’s not referred to as a replenishment mechanism even if it is one. And the ‘problem’ with it (at least as far as the WGSF sees it) is that it’s not a multisectoral replenishment mechanism (i.e. the private sector is not invited to contribute). There are good reasons for a member-state-driven replenishment model, though: member states are extremely durable (unlike non-state actors such as banks, financing partnerships and foundations); are diverse in terms of ideological disposition; are subject to the norms of international relations; and have an existential interest in ensuring that WHO is replenished. Non-state actors such as banks, financing partnerships and foundations have non of these benefits. If you want as close to a guarantee as you can get that 100% of WHO’s base budget will be sustainably funded by fully flexible funds, then it be better to retain WHO’s member state-driven replenishment mechanism and work harder on making it work for the entire base segment.
The Secretariat’s report then considers principle 2 (that a replenishment mechanism must satisfy WHO’s need for flexible funding and donors’ need for WHO to account for the money it receives). This request from donors for accountability is a common refrain in the long history of WHO funding reform, but it could take a novel turn if the multisectoral replenishment model is adopted. Billed as a constituency-driven requirement from donors (given the tiny amounts of money being considered, I think member states make way too much of this requirement), the replenishment mechanism could now give to non-state donors as much a right to request accountability from WHO for the money they donate as member states. This could, in turn, increase the ‘voice’ (read influence) of private funders to WHO in how the Organisation funds the base segment of its program budget (i.e. the segment that funds the Organisation’s main strategic health priorities). Is that what WHO wants? We know from the contributions from Gavi and the Global Fund at the WGSF meetings that their governance structures allowed for much more donor influence in the allocation of funding, so safe-guarding WHO from this eventually would have to be a key priority.
The main point of discussing a replenishment mechanism is to find a way to ensure that more flexible funding goes to the base budget. The figure below is a good starting point to think about this (it’s a screenshot from WHO’s budget portal showing funding to the base budget for the program budget 2020-21). It shows how much ACs (member state contributions and the most flexible funding) and VCs go to the four priority areas of the base segment. The WGSF recommendation to ensure that 50% of the 2020/21 base segment be financed through ACs by 2030 means that the replenishment mechanism would be looking to match the other 50%. If it works, then WHO would received that fully flexible funding and be able to fill ‘pockets of poverty’ such as the one you can see for the health emergencies priority area (which is one of WHO’s least funded priorities at the moment). This would be a good result.
However, there are lots of reasons to be skeptical of the idea of a replenishment mechanism. It might help if I just list them. So, in no particular order, the main ones I can think of are:
- Securing the funding required – would the donors contribute? What is the incentive? Why would non-state donors want to fund the WHO through replenishment rather than just continue to fund in the way they do currently? There doesn’t seem to be any obvious benefit to them so how would you secure buy-in? And would other donors see the replenishment as an opportunity to contribute less to the WHO and decide to leave it to the new non-state funders?
- Broadening the donor base or just reinforcing WHO’s reliance on the usual big donors? Foundations already contribute significant amounts to WHO, so wouldn’t this be an invitation for them to contribute more?
- Influence of the non-state sector. It’s no secret that Gates doesn’t like the way that WHO is run. He would now have an opportunity to influence the base budget, which includes all the governance issues he, personally, doesn’t like. Would we see the tail wagging the dog – where donors subtly seek to influence WHO’s health priorities under the cover of a replenishment?
- Governance structure. Does a replenishment model fit with the complex governance arrangements of WHO? How amenable to results-based reporting would WHO’s broad mandate and Constitution be for the replenishment mechanism?
- Short term impact vs mid-long term funding. Donors to the replenishment may require the former while WHO would need the latter.
- Setting up the mechanism. How resource heavy would this be? Where would it sit and who would manage it? Are we going to see yet another global health governance funding mechanism, led by an ex-McKinsey, ex-banker? Can you imagine cheap beer fan Peter Sands taking on the role?!
There are probably many other objections that I don’t have the wit to see. There’s an obvious benefit of a fully flexibly funded base program and I hope the Secretariat manages to achieve this at some point. But it’s immensely disappointing to see the ambition of the WGSF in only recommending 50% of the 202-21 base segment funded by ACs by 2030. This is a clear indictment of the commitment of member states to WHO. There’s nothing worse than listening to upper-middle-income members complaining about cost when they a) spend SO much more money on other – often trivial – things, b) spend much less than lower-middle-income countries, and c) not seem to appreciate how much they would benefit if they properly invested in the Organisation. Have they not read the investment case? Instead of flexibly funding WHO via ACs, we are now seriously considering outsourcing the funding of WHO’s core work and actively seeking private sector support.
Besides that, I’m struck by the influence of the IPPPR panel’s recommendations in the replenishment mechanism deliberations. We have Helen Clark to thank for that and, I suspect, Mark Dybul and Michel Kazatchkine. When you look at the WGSF meetings, there is really very little consideration of the problems of a replenishment (or if discussed then not documented in any detail in the meeting notes). Instead, the IPPPR recommendation is floated early on, a step-wise decision-making process requires decisions in order to progress, which puts pressure on reaching a consensus. As problem-identification and solution-seeking processes go, this is not how WHO should conduct its meetings. There are much better and effective ways of doing it than this.
Please remember that at the end of the day we are talking about very small amounts of money. I can’t emphasise that enough. But instead of paying up, yet again WHO’s member states make a big song and dance about how costly it all is and make WHO’s secretariat jump through hoops for the promise of crumbs. Think about how much time and resources has gone into this already, and then how much will it will require to take the idea forward and actually implement it. Although it’s early days, my gut tells me that the replenishment mechanism is not the way to go. But I fear we are going to get it.