The fact that I am from Barbados, one of the WHO’s smallest Member States, sends a signal as to how important the WHO and global public health is to my small island state. Multilateralism and multilateral institutions are crucial to us all but especially to the most vulnerable. This Executive Board is meeting at a time when the primacy of global health governance is under severe scrutiny, multilateralism as we know it – particularly in the global health sphere – is under threat; and unrelenting and unforgiving climate crisis, heightened geopolitical tensions, as well as conflict within and among countries, pose real and lasting risk to global health.
Jerome Walcott, Chair Executive Board, Opening address, Session 1.
As there is nothing else going on in global health at the moment, I imagine that you have all been glued to your seats watching the proceedings of the 156th meeting of the World Health Organisation’s Executive Board (EB). The EB is still in session (like Musk, delegates will have had better parties to attend this weekend; unlike Musk, they have decided instead to spend their time constructively supporting global health, rather than trying to dismantle it). You can still watch the week’s discussions on catch-up over on WHO’s EB governance page. Time is short so, to those of you TLDW who might need some direction, in addition to watching session 3 on financing (which I’ll be reflecting on below), you could also usefully watch sessions 6 (Mental health and social connection) and 9-10 (Health conditions in the occupied Palestinian territory, including East Jerusalem). Each of the EB’s sessions covers vital work, of course, but I single out the United States’ delegate’s intervention in session 6 (2:39:38) and the Israeli delegate’s interventions in sessions 9-10 (1:15:22 in S9 and pretty much all of S10) as being particularly noteworthy. Make of them what you will (there is much to be said) and then please join me in appreciating the patience of the EB’s Chair Jerome Walcott (who I quote above).
Session 3 was devoted to discussion of document EB156/26 Rev.1 Financing and Implementation of the Programme Budget 2024-25. Additionally, document EB156/INF./5 Overview of Draft Resolutions and Decisions, and their Costings was shared just prior to the session. This is an important document that will likely directly inform the (de)prioritisation exercise the Secretariat will be doing in consultation with Member States between now and the WHA in May. Across all the reports by the Director General (DG), there are 19 resolutions and decisions, 12 of which “have cost implications”. Additionally, Member States (MS) are proposing 20 decisions, which will also need funding. In total, to fund them all would cost $840m. They wouldn’t all need funding immediately though – for the current biennium 2024-25 the cost would be $128m of which $81m was already allocated. Unfortunately, that $81m is now looking in doubt as a consequence of the US withdrawal from WHO (and with it its funding). For the next biennium, 2026-27, the Secretariat would need to allocate $328m if it wanted to finance all the resolutions and decisions. What to do? The Secretariat in EB156/INF./5 presents three proposals to the EB:
(1) adopt the resolutions as proposed and ask the Secretariat to de-prioritize other activities to allow for implementation of resolutions within the defined budget envelope; (2) postpone adoption of all resolutions by one year to 2026; or (3) approve the resolutions but with a provision that their implementation, other than advocacy for the topic at minimal costs, should be postponed until the review of the programme budget proposed for 2026.
Because the document was shared too early for most delegates to be able to comment, most didn’t. A couple of delegates did, though (Spain and Slovakia), and they indicated a preference for option 1 and 3. It’s hard to see an obvious preferred option, and I could even imagine non of them being acceptable. The Annex in the report provides a handy table with costings and notes against each resolution/decision. It’s hard not to see financing of the Draft Global Action Plan on Climate Change and Health as being vulnerable. The EB is discussing this item today (Saturday), so it will be interesting to review the discussion and try to read the room.
Returning to document EB156/26 Rev.1 Financing and Implementation of the Programme Budget 2024-25, I would start with Israel’s comment in Session 1 in response to the DG’s opening Address to the EB:
“The main problem is not the budget. The budget is a huge problem but, still, leaving this organisation – the most relevant health Organisation in the world – and avoiding a domino effect of other states; not necessarily withdrawing but, rather, losing interest in this organisation, as well as other international bodies, companies, industry, academia. In the sake of this Organisation, we must find the route to have a productful [sic] discussion with our American colleagues and see if there is a path to revise their decision”.
One of my main takeaways from the subsequent discussion in Session 3 on the program budget is that there is no evidence to support the Israeli delegate’s concerns of a ‘domino effect’. In addition to the US, the only other country to fall has been Argentina, whose President Javier Milei announced his decision to leave WHO on the 5th Feb (i.e. the day after Session 3). I do not expect any other country to withdraw, although after Israel’s exchange in Session 9-10 one could conceivably imagine that country following the US. Neither Argentina nor Israel contribute any significant sums to the WHO, so their loss would not be financially significant. I don’t seriously think Israel would withdraw, but Netanyahu and Trump are close at the moment.
The title of this post comes from the Spanish delegate’s intervention at Session 3 (1:01:30) who offered the WHO “an unequivocal message of support” and further that “in this time of uncertainty, WHO needs to be braver than ever” – where ‘brave’ means “being smart and being at the forefront of health protection…and realising that the cost of inaction may be higher than anything else”. China was also clear in its support, noting: “WHO is of paramount importance. Especially in the current context, its role should be strengthened not diminished”. Poland – representing the European Region – declared: “In these difficult times, we stand by the side of WHO”, Senegal – representing the African Region – called for “active solidarity”, and Germany was “fully committed to a strong and independent WHO”. Practical, not existential, issues occupied the discussion of the 2024-25 budget, with MS primarily concerned with ensuring an equitable allocation of resources across the WHO’s three levels.
Between now and the WHA, the Secretariat is very clear about what it is going to do to mitigate the financing gap it currently faces as a consequence of the US withdrawal. The DG described the strategy in his Report which he presented to the EB in the opening Session, and this was summarised by Assistant DG (Business Operations) Raoul Thomas during Session 3. In essence, it’s a ‘two-pronged’ approach: resource mobilisation and strategic prioritisation. Thomas clarified that the WHO’s Resource Allocation Committee has responsibility for allocating all the flexible funding received from donors and confirmed that 80% of those funds are allocated to the regional and country offices. The RAC doesn’t have any control over the allocation of non-flexible funds, and so where these go is down to donor preferences. Consequently, the request by MS for the Secretariat to ensure equitable allocation of funding is very much the responsibility of MS. Hence, the Secretariat is calling on MS to ‘un-earmark’ some of its earmarked funding, so that the Secretariat can do what it is being asked to so. Thomas struck a confident note in response to a point of clarification from Switzerland: on the question of cash flows, Thomas told delegates that “it’s fine until the 1st quarter of 2026, assuming nothing else changes” – by which he meant that he was expecting additional (not fewer) resources to come WHO’s way in the interim. Assistant DG (External Relations and Governance) Catherina Boehme also emphasised that mobilisation of resources was very much underway and that the Investment Round is not over. But, WHO needed MS to convert pledges into agreements, and agreements into “money in the house”.
In the short-term, the WHO is in relatively good shape. That might seem counter-intuitive, but as EB156/26 Rev 1 points out, the base segment is 89% funded (including projections) as of 30 Sept 2024 – a 10% increase from the same period for the previous biennium. During session 3, Brazil intimated that it had had sight of a more up to date document (presumably circulated during PBAC and good to 31 December 2024) reporting that the base segment was 99% funded. Even the ‘heatmap’ that delegates were focusing on – the graphic that visualises by colour where resources are allocated across the different levels of the Organisation) – is likely to get much greener in the coming months as current funding is allocated. So, it’s not all doom and gloom!
Andrew
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