Opinion: 5 ways to buttress WHO’s financing ambition

The 194 nations that govern the World Health Organization took their first tangible steps during the 2023 World Health Assembly to fulfill the commitment they made one year ago to sustainably finance the U.N. agency tasked with the “attainment by all peoples of the highest possible level of health.” For a chronically underfunded institution, this is welcome news — and there are some tangible steps that can be taken to maintain progress and fix its financing model once and for all. The WHA delivered on two key promises: First, it agreed to raise the dues governments pay to a level equivalent to 26% of WHO’s 2022-2023 base budget. If this sounds underwhelming, consider that such fees — dubbed “assessed contributions” — had declined over time to a much smaller fraction of its revenue, making WHO dependent on the less predictable voluntary contributions of a handful of powerful donors. This boost is the first in a series of increases that could see member dues rise to the equivalent of 50% of the 2022-2023 base budget by the decade’s end. The second promise kept was to permit planning for an “investment round” in 2024, likely to include a replenishment conference. The goal would be to “raise voluntary contributions for the … base segment that is not funded by assessed contributions.” Much debate has centered on whether donors would be permitted to earmark their pledges. These contributions are critical resources and part of the overall strategy of sustainably financing WHO. They are also politically palatable to donors conscious of national priorities and citizen accountability. Overreliance on earmarked voluntary financing, however, has created a piecemeal and fragmented agenda at WHO, where the organization cannot control its own budget. That’s untenable. Important but unglamorous components of its activities — from standard setting to talent retention — have been underfunded, as have major causes of morbidity and mortality such as noncommunicable diseases, injuries, and mental illness. On the other hand, more predictable and flexible revenue should give WHO a better ability to manage how it expends resources over a longer time horizon and manage operations. There is a long way to go to ensure a robust, amply funded WHO. Here are five ways to stay on track. 1. Promote the economic value of investment Political leaders are under relentless stress to demonstrate public funds are used well, and surges of nationalism coupled with perceptions of U.N. bureaucratic inefficiencies increase pressure. Meanwhile, persistent inflation and recessionary fears add to economic uncertainty. Against this backdrop, arguments for fully flexible funding could be a tough political sell. WHO must promote a compelling case for global solidarity, demonstrating that such investments are a great deal for taxpayers. For example, so much public health spending is geared toward expensive crisis response rather than preventing emergencies in the first place. WHO’s latest investment case highlighted its “leadership role in the international system for prevention” and that “investing in WHO provides a return of US$ 35 for every US$ 1 invested.” Moreover, the approximately $1 billion in assessed contributions that will flow to WHO over the next two years pales in comparison to the $12.5 trillion cost to the global economy of the COVID-19 pandemic. These are captivating economic arguments that WHO should relentlessly communicate to policymakers and the public. 2. Mobilize familiar methods from the nonprofit sector Strategies to generate flexible funding are plentiful in the nonprofit sector. Philanthropic donors often restrict their giving to particular purposes, so nonprofits organize capital campaigns and annual funds to generate finance “without donor restrictions” to underwrite more prosaic — but essential — operating costs. WHO should analyze the best-in-class capital campaigns to fill out its method. WHO must also ensure the full recovery of its costs. These include both direct costs that are clearly attributable to performing work on specific initiatives, as well as indirect costs that are incurred for common or joint purposes. Financing WHO’s external audit is one example of an indirect cost, an important exercise “to provide independent assurance to Member States,” but one that is not readily assignable to a specific WHO program. Activities like these are not well-positioned to attract earmarked finance. Flexible funding and member dues can be used to pay for them, but it is also appropriate for WHO to negotiate and charge a fair and evidence-based “indirect rate” as nonprofits do. In 1981, the WHA capped the indirect rate that WHO is permitted to charge at 13%, which it admitted covered only “partial reimbursement” and now lags universities and others that charge much higher rates. This outdated cap must be raised to something that permits WHO to recover the full financial outlay of its work. 3. Use a familiar replenishment model WHO has never held a replenishment conference and member states wish to understand how it will work and may heavily negotiate the rules of engagement. Tamping down uncertainty is critical. Adopting the replenishment playbook that the Global Fund to Fight AIDS, Tuberculosis, and Malaria and others pioneered would give member states a sense of how WHO replenishment would work. To the extent WHO’s model differs — for example, earmarked donations could be capped at a percentage of unrestricted donations — the reasons must be clear. 4. Leverage public sector money to drive private sector investment New funding pools may be needed for truly additive investment. Public money can incentivize private finance and so multiply the effect of taxpayer investment. Still, government money must lead, and adequate safeguards, including those embedded in WHO’s Framework for Engagement of Non-State Actors, must be carried out to prevent undue private influence. While some may be skeptical, we already know public finance is insufficient and that whole-of-society solutions require an inclusive, team approach. 5. Embrace and empower civil society Civil society organizations often provide the engine for mobilizing political will to propel funding. WHO has lagged behind others in engaging nonstate actors, which is understandable given membership is restricted to national governments. Yet the Global Fund and similar institutions that hold investment rounds incorporate civil society into their strategies. WHO will need bottom-up social mobilization, lobbying governments throughout the world to step up. WHO is hardly the first international organization to rely heavily on voluntary, restricted contributions, but having become an extreme case, the WHA’s decisions to raise dues and pursue an investment round can make the organization’s finances less volatile. Keeping the momentum is critical, as is transparency and accountability for how more flexible funding will lead to better outcomes. There are more promises to keep if we expect WHO to become the agency we badly need to make the world healthier, safer, and fairer. Editor’s note: The views in this piece do not necessarily reflect the views of the O'Neill Institute or the FNIH.