For a long time, the World Health Organization (WHO) has experienced immense financial stress resulting in numerous debates on how to remedy its economic woes. A working group set up earlier this year has been tasked with finding long-term solutions.

Each year the representatives of some 194 countries make demands on what work should be carried out by the WHO, but the money needed to carry out the requests is severely lacking.

Björn Kümmel, deputy head of the global health division at Germany’s Federal Ministry of Health, and chair of WHO’s Working Group on Sustainable Funding, recalls explaining the situation to his daughter who asks what the money problem is.

“The family decides to have breakfast with lots of friends. We need to buy 20 buns from the bakery, and there’s a plan in place because we know our guests want different buns. I send my daughter to the bakery to buy 20 different buns but only give her enough money for two,” he says.

Without enough money, Kümmel’s daughter would have to beg for money on the way to the store. Some generous passersby might give her some change, but on the condition that she spends it on specific types of buns. She might be able to bring back home all 20 buns but to a large extent they will not be the ones ordered.

“It sounds absurd when we put it this way but the member states of the WHO, in the same way, do not provide the finances to fund their own priorities agreed to by these countries,” Kümmel told Geneva Solutions.

Increasingly, individual donors have been providing funding money for these “buns”, but often face criticism for financing projects that personally interest them.

Meanwhile, the funds needed to execute the activities of the ever-broadening agenda set by the World Health Assembly (WHA) are lacking. COVID-19 has revealed major discrepancies between the expectations of the WHO and its de facto ability. “The pandemic has shown that we need a strong WHO, now more than ever, and it is clear that it is not strong enough,” Kümmel said.

Sustainability lens

For years discussions have circled around WHO’s funding, prompting its Director-General, Dr Tedros Adhanom Ghebreyesus, to reflect on how these conversations have “remained rather abstract” in a report delivered to the Executive Board.

As a result, the WHO created the Working Group on Sustainable Financing (WGSF), which is tasked with finding long-term solutions to the body’s financial troubles.

Kümmel notes that although finances remain a popular topic amongst the organisation’s members, this is the first time a “sustainability” lens is being adopted. He adds that everyone shares the view that a stronger WHO is needed, which requires more stable sources of long-term funding.

The alternative, continuing with the status quo, poses a threat to global health security and the achievement of the Sustainable Development Goals.

“There needs to be a completely new approach to ensure the WHO has the right finances in place in order to fulfil the world’s expectations,” he says.

The WSFG is working on a proposal that will “enable WHO to have the robust structures and capacities needed to fulfil its core functions,” as highlighted in the meeting report. The final report and recommendations will be taken forward to the WHO’s executive board in January 2022.

Concluding their third and most recent meeting in June, the group has already explored different financing models, including other global health actors’ funding structures that could help recharge the WHO’s coffers, drawing on lessons from other health actors.

Adopting the Global Fund’s so-called replenishment model, for example, would mean raising funds in multi-year cycles. Kümmel says the WHO budget could at least be partially funded this way.

Since taking office in 2017, Ghebreyesus has made broadening the WHO’s funding base one of the organisation’s main priorities. In 2019, he announced plans to establish the WHO Foundation to secure funds from the public, individual major donors and corporate partners.

The launch of the independent grant-making body came amid controversy over former US President Donald Trump’s decision to halt funding from the US, the WHO’s single largest donor.  The move was later reversed by current President Joe Biden but it had already exposed the health organisation’s heavy dependence on a few major donors.

Approved for 2020-2021, the budget is $5.8 billion, which reflects a $1.4bn increase from the previous biennium, mostly needed for the Covid-19 response. About 16 per cent of this figure stems from mandatory payments known as assessed contributions, paid by its members, which over the last two decades or so, have remained flat at one billion US dollars.

The other way is through voluntary contributions, secured from governments, other UN agencies and the private sector, which make up the majority of the budget.

In recent years the top voluntary contributors, in addition to the US, have included the United Kingdom, Germany and the Bill and Melinda Gates Foundation.

Yet, private players such as the Gates Foundation have come under fire for having some of the most powerful and influential voices in global health, raising questions about the WHO’s independence.

Praise for ‘Big Philanthropy’ donors

Kümmel, however, believes “these voluntary generous donors should be praised because they provide the needed funding in the absence of member states”.

The vast majority of funds coming from the private sector go to the Polio Eradication Initiative, he points out.

“If the WHO didn’t receive these resources, we wouldn’t even be close to an eradication of polio because many member states just don’t put the money on the table,” he adds.

In the last 10 years, the UN health agency has depended heavily on voluntary contributions, which can include both flexible funds untied to specified causes as well as money that can only be spent on activities decided by the donor. Still, in 2018/2019, almost 70 % of the overall budget was financed by funds allocated for specific purposes.

The working group has considered whether the core mandate of the WHO should be fully funded by “un-earmarked” flexible contributions, which favours the organisation’s aspired ways of working, whilst also exploring the importance of expanding the WHO’s donor base.

Following the recommendations of the Independent Panel for Pandemic Preparedness and Response (IPPPR), who share the view that two thirds of assessed contributions should be dues paid by member states, the working group are toying with the idea of whether this figure should be at least 50 per cent, a proposal that has been put forward to the regional committees, which Kümmel expressed had been received constructively and positively.

In addition, the group has put forward to the regional committees whether member states would support and agree to the proposal on increasing assessed contributions as well as adopt an incremental implementation schedule at next May’s 75th WHA.

Contributions from all member states

For Kümmel, all member states should contribute regardless of their economic status. However, he agrees that some countries experience severe financial challenges, thus the current mechanisms in place ensure financial possibilities are accounted for.

At the moment each country is assigned a share of the assessed budget through the WHO’s scale of assessments proportional to the size of its economy, but ultimately it is up to member states to fork out the money, particularly if it is un-earmarked funding.

Coordinated efforts across regions are vital, especially when faced with health crises such as the Covid-19 pandemic. If paired with the loss of funds from major contributors, the results can be devastating.

In 2020, the US fell to the third largest donor position, providing about 8% of the overall budget in the first three quarters. Biden has since restored ties with the body and in February pledged $4bn to the WHO-backed COVAX initiative to boost the equitable distribution of COVID vaccines, however, the full effect of this is yet to be seen.

Germany has similarly reinforced its support to WHO’s work and fight against COVID. Earlier this month the WHO launched its new Hub for Pandemic and Epidemic Intelligence in Berlin. Germany has said it will make an initial $100 million investment to prop up the facility.

The Hub is said to focus on “collaborative intelligence”, where all 194 member states, scientific institutions and civil society could share information openly.

As the coronavirus has demonstrated, the world is not ready to rapidly spot and tackle potential pandemics. The working group believes preparing the health body against such future challenges with the appropriate resources is crucial.

“I think that it is quite clear that the strengthening of WHO post-COVID is a key priority for many countries including Germany. Member states who really want to strengthen WHO understand that ensuring sustainable financing to WHO is one of the key pillars of this,” Kümmel urged.

“We are very supportive of constructive multilateralism in global health. WHO is the global health forum where everyone sits at the table, all 194 Member States, it has a broad global health mandate, and it is fully inclusive.”

This article was first published by Geneva Solutions.

Image Credits: WHO/ Violaine Martin, WHO.