WHA 78 – a ‘crossroads’ for global health?

Only joking! I hate that stupid metaphor. Only amateurs use it in their writing – begone amateurs. Be. Gone.

Anyway, where were we? Oh yes, it’s World Health Assembly time, a time when delegates from all four corners of the globe – the North, East, West and South – converge at a fixed geographical location and decide the future direction of global health. Should it go this way, should it go that way? Much like meeting at a crossroad…gah, no! It’s not a fucking crossroads!! Linda, LINDA! Tell them, TELL THEM!!*

Stale metaphors aside, what can we expect at the WHA this year? As is my want, I’ll just focus in this post on some financing and funding highlights as they seem to be more than mildly important this time around. For the TLDR crowd, this is what I think we all need to keep an eye on:

1. The 14th General Program of Work (GPW). Read it again. It’s the WHO’s four-year strategy document. Pay close attention to the assumptions that underpin it – these two in particular: sustained political commitment and sufficient financing. We’ll find out next week whether those assumptions are moonshine.
2. Priority setting. It’s all over the draft 2026-2027 programme budget and it’s important to understand the process, and to think carefully about why it’s being done. Priority setting is a response to financing challenges and a necessary exercise for the WHO to retain its legitimacy in the eyes of its donors and its staff.
3. Voting rights. Voting rights is likely to be a discussion point at this year’s WHA probably because people are wondering whether the US will be able to continue to vote if it doesn’t pay its ACs. I think it’s a bit early to be discussing this but that’s not going to stop the conversation!
4. The financing gap. Not to be confused with the funding gap, the financing gap – ie the gap between how much the WHO spends and how much revenue it receives – was $450m in 2024, which is a reduction of $90m compared to the gap in 2023. But it’s still $450m. The main document to read here is A78/18 Audited financial statements for the year ended 31 December 2024 and A78/19 Financing and implementation of the Programme budget 2024–2025. The main focus of discussions at WHA78 will likely focus on staff salaries and discussions around the internal reorganisation of the Geneva HQ.
5. The funding gap. Funding to the WHO is currently in a state of – how might one put it – FUCKING CRISIS! In what can only be described as an exercise in collective insanity, MS are reigning in their voluntary contributions (VCs) to WHO and getting cold feet on their commitment to increase their ACs (looking at you China). The Investment Round has attracted barely a quarter of the $7bn in VCs required to fund the GPW 14 and, of course, the United States – historically the largest donor to the WHO – is withdrawing from the Organisation and taking its money with it.
6. A new budget line! For budget watchers, this is as exciting as Christmas. The last one was in xxxx when Chan introduced the Emergency Operations and Appeals budget line.
   

Below, for anyone who still identifies as NLDR (not lazy, do read), are some detailed reflections on all of the above points.

The 14th GPW is the WHO’s main strategy document. I don’t remember writing about it a couple of years back, but I did. I seemed to be annoyed by its ‘5Ps’ structure: promotion, provision, protection, powering (ugh), and performing. But it’s important to re-read it because this is the document where the 14 Joint Outcomes come from that form the basis for the priority setting exercises of the 2026-27 program budget. These JOs are underpinned by 6 Strategic Objectives (climate change, the determinants of health, PHC/health systems, health services, health risks, and health emergencies), and underpinning these objectives are 5 Assumptions (see image below).

Part of the reason why the WHO and the WHA are so important is because they provide a forum for public political expression. This is a rare opportunity for diplomats, and probably explains why so much attention globally is given to the WHA. Where else can health ministers diplomatically tell – on the record – Russian and Israeli diplomats to fuck the fuck off with their invasions and genocidal actions? The WHO cares about the oppressed, it actually gives a shit when hospitals are bombed, and it reminds us that a) health is a human right and b) everyone is equal and no-one should be left behind. But…it requires commitment from its MS and partners. The Secretariat cannot do that on its own. I think we will see very strong statements of political commitment for the WHO and the 2026-27 program budget from pretty much all of the WHO’s MS/partners – political commitment like this from the EU. However, the fact that the Investment Round has so far only attracted $1.7bn of the $7.1bn in VCs from state and non-state donors, and the fact that Tedros has reduced the base segment of the program budget since the Executive Board in February (from $4.9bn to $4.2bn) suggests that political commitment is not translating into sufficient financing. Words ≠ actions.

Priority setting is given significant attention in the proposed program budget 2026-2027 – more attention than any other program budget. The need for prioritisation, according to the Secretariat, comes directly from – and was “a major recommendation” of – a couple of recent independent evaluations: the Independent Evaluation of the 13th GPW (conducted by PriceWaterhouseCoopers) and an Independent Evaluation of WHO’s Results-Based Management Framework (conducted by Roger Grew and Florianne Gaillardin). We can quibble over adjectives like ‘major’, if you like. The PWC evaluation on the 13th GPW found “room for improvement in prioritisation” consistent with another evaluation (this time on WHO’s normative functions) it did recently. The evaluation on WHO’s normative functions didn’t conclude that there was a need for prioritisation, just that there were areas where the evaluation process could be improved – country-level feedback loops, for example. So, I suspect there are additional reasons for the priority setting process that go beyond the warm words around ‘impact’ and ‘coherence’ and “focusing on areas with the greatest potential for significant health improvements”. I think that the Secretariat is conducting priority setting exercises because it understands that donors either don’t trust or don’t want the Secretariat to make the call on what health issues it thinks should be funded. So, it has to fall back on a process that has the blessing of global consultancy companies like PWC and which is less political and more ‘neutral’.

It’s bullshit of course. I mean, you only have to compare the health issues that countries prioritised for the draft proposed 2024-25 program budget with the 2026-27 priorities to see that. I’ve put the top five from each into a table below. The ‘ranked high’ column is simply the number of countries that ranked the outcome as ‘high’. To be clear, exactly the same process was followed in each case. I think what the table illustrates is the ‘magic’ that can happen between the beginning and the end of a process in order to achieve a result. PHC appears in the top five in both – but it’s in the context of some quite specific demands in the 2024-25 exercise (access to essential medicines, for example) that are lost in the subsequent budget. Health emergencies, too, appears in both but the demand is for detection and response in the 2024-24 budget while it’s a demand for readiness and resilience in the 2026-27 budget. Of course, it could just be that countries are fickle beasts and change their health priorities from one biennia to the next. Either way, words matter.

Personally, I think conducting consultation exercises is playing with fire. The reports are at pains to stress that the ranking exercise is not about which health issues are more or less important, and only about which health issues countries most technical support with. But is that subtlety going to get lost in discussions? At some point, the concept of leadership needs to be revisited in the broader discussion of what WHO do ‘we’ want. It feels too much like the Secretariat is facilitating more than leading through these prioritisation exercises, and has lost the confidence to make decisions that it thinks are best for global health. This is important in the context of health issues such as climate change that aren’t yet threatening all regions equally. Joint outcome 1.1, for example: “More climate resilient health systems are addressing health risks and impacts”. Only 55 MS ranked this outcome as ‘high’ and only one Region (the Western Pacific) put it amongst its top 5 priorities. You can argue to the contrary but my feeling is that these currently ‘low priority’ outcomes will struggle to remain funded.

Document A78/23 Status of collection of assessed contributions, including Member States in arrears in the payment of their contributions to an extent that would justify invoking Article 7 of the Constitution is the document to read to get to grips with the voting issue. It’s an issue because 11 (12 if Bolivia is included) Member States (MS) are “in arrears in the payment of their assessed contributions (ACs) in amounts that equal or exceed the amounts due from them for the preceding two full years” (A78/23 p4) and so have had/will their voting privileges at WHA 78 suspended in accordance with Article 7 of the WHO’s Constitution. MS will also be voting on 6 further MS who are in arrears, and who may therefore have their voting rights suspended for the next WHA in May 2026. The United States is in arrears for one year of ACs, so it can continue to vote this year at WHA 78. If it doesn’t pay up in 2025, then the WHA will vote at next year’s WHA to suspend US voting rights for WHA 80. So, the US is good to vote until at least 2026 and then it remains to be seen. Note that the voting issue is separate from the withdrawing issue, and I can also imagine that there will be plenty of convos this year about the legal implications of a US withdrawal from the WHO. Because this isn’t Trump’s first WHO withdrawal rodeo, there are some earlier analysis on this that remains relevant. The best summaries I’ve read are from Jean Galbraith and the CRS, both from 2020.

I don’t know how much more I can write about financing and funding the WHO. It feels like I am watching the Organisation evaporate in front of my eyes. Maybe as I walk around the Palais this week kicking the peacocks (by which I mean some of the self-important delegates not the birds), bits of the infrastructure will begin to fade like Marty McFly in Back To The Future. In truth, it doesn’t require anything remotely as complicated as attaching a cable to a church steeple to harnass the power of lightning via the hook up of a time travelling DeLorean DMC 12 to bring the WHO back to life. IT JUST NEEDS MORE MONEY. I’ve written many posts making this point, so I won’t labour the point again here. My published research suggests scope for upper-middle-income MS to contribute more VCs and MS should be ‘thinking big’ not ‘thinking small’ when it comes to sustainable funding. If you want to know what I think about the financing gap, please take a look at my last post The WHO is an institution you should care about and take its side. I’ve found that the best way to make the point is through absurdity. Fortunately, Qatar came up ‘trumps’ (pun intended) this year. Below is an image I used last week in a presentation. It’s the interior of the Boeing 747-8 Business Jet – aka the P4-HBJ – that Qatar has recently gifted to Trump. It’s valued as $400m and coincides with a $96bn trade deal between Qatar Airways and Boeing for the purchase by QA for 210 Boeing jets. Qatar donated $5.9m to WHO in 2024. Do the maths = $400m = 67 years of funding that Qatar could have ‘gifted’ to the WHO instead.

In addition to reading the 2024 Audited Financial Statements for the year ended 31st December 2024 (A78/18) do also give A78/19 Financing and implementation of the Programme budget 2024–2025 a bit of love. It’s a good read because it quantifies the immediate effect of the US not paying its ACs in 2024. For 2024-25 – ACs dropped from $1148 to 887m (-$261m). It’s good news that the base budget is 96% funded but that still means a 4% or $210m shortfall. Taken together and, according to the calculations in the document, this has resulted in a forecast salary gap of $317m. Thanks Biden; thanks a fucking bunch! I’ve shared the graph below on BlueSky but I might as well share it here too. I think it accurately reflects the US’ funding to the WHO over the last few years. Hopefully, it’s self-explanatory. The data come from the AC and VC documents shared on WHO’s Governance pages (I don’t use the WHO’s online budget portal in any of my analyses).

Ok, ok, I’m reading the room and it’s time to draw this post to an end. I doubt that the Global Technical Centres will get much media attention but it feels like a significant development to me. If approved, the 2026-27 budget will have a new budget line for Global Technical Centres: Five ‘outposted centres’ (a Traditional Medicine centre in Gujarat – not new, it was established in 2022; a Hub for Pandemic and Epidemic Intelligence in Berlin – also not new, it was established in 2021; the WHO Academy in France, established in 2021); a new Hub for Global Health Emergencies Logistics in Dubai; and a UHC Knowledge Hub in Tokyo that is currently under development) which, combined, will constitute “the equivalent to a major office”. $78m will now go to the new centres from the HQ budget.

If you’re in Geneva this week, let me know (unless you’re a delegate from Israel, Russia, Hungary, Argentina, China, the US, in which case you can f…[redacted]).

Andrew

* With apologies to Daz Black