MANILA — When the World Health Organization’s executive board meets next month, one of the top items on the agenda is expected to be the agency’s proposed budget for the next two years. The talks among the organization’s leaders and member states will give insight into how effective and convincing the sweeping changes WHO initiated in the past year have been. The United Nations agency is also expected to reveal more about the viability of its first investment case as it seeks to raise billions of dollars in funding to deliver on its priorities for the next five years.
“The SDGs belong to all of us, and the resource mobilization task also belongs to all of us. So there is a shift and that's what we want. And if donors accept this shift, what they will do is they will be standing side by side with us to mobilize the necessary resources,” WHO Director-General Tedros Adhanom Ghebreyesus told Devex in an interview.
Over the next five years, the organization will need some $14.1 billion, according to estimates in the investment case released in September. This will be used to help deliver the organization’s much-touted “triple billion” goals of protecting 1 billion more people from health emergencies, reaching 1 billion more with health coverage, and improving the health and well-being of 1 billion more people.
In this special report, Devex looks at Tedros' top accomplishments to date, and what the future may hold.
For the first time, with the investment case, WHO is giving member states a peek into its longer-term requirements to help inform budget negotiations. It is part of the changes Tedros has initiated at the U.N. health aid agency since coming to office in 2017.
In interviews, Tedros and two of his directors — Imre Hollo, director for strategic planning, and Dominique Hyde, director for strategic engagement at WHO — laid out the strategies they are exploring and implementing to raise funds. These range from changing the narrative around resource mobilization, to employing different mechanisms to broaden the donor base. They also shared with Devex details behind the numbers WHO is seeking from member states.
“We always think about health expenditures as expenditures, and this is the first time that we actually come and show that this is an investment that brings about concrete results,” Hollo told Devex.
Where will the money go?
The investment case outlines some of WHO’s achievements to date, its “unique” roles in global health, as well as how much member states can expect in return for every dollar invested in each of the three pillars of WHO’s triple billion target. $1 invested in expanding universal health coverage shows a return on investment of $1.40 for example. The ROI is higher — $8.3 — for each dollar invested in preventing health emergencies.
But it’s the headline numbers that draw attention:
These numbers include increased investments in country capacity ($667 million), polio function mainstreaming ($300 million), as well as data and innovation ($296 million).
Increasing country capacity is what Tedros has been pushing for since taking office and is also aligned with WHO’s general goal of driving more impact at the country level. Investments in data and innovation, meanwhile, are meant to help member states accelerate progress to reach the health-related Sustainable Development Goals, Hollo said. Data can help countries better target their interventions, and innovation can help them find better solutions, he explained.
Investments in humanitarian response and emergencies will help attain the key goal of reaching 1 billion more people during emergencies. The multiple outbreaks that hit this year, from Ebola to cholera, show how much countries still need to strengthen their preparedness and response to health threats.
The money WHO is asking for is meant to help countries prepare, prevent, respond to, and detect disease outbreaks and health emergencies. This includes strong implementation of the International Health Regulations, and ensuring WHO has the means and capacity to respond to health crises globally.
A crucial aspect, however, is funding flexibility. Despite the critical role WHO plays in outbreaks and health emergencies, much of its funding is earmarked, creating a difficulty in reallocating resources where needed.
“If you have flexible funding, the advantage of that is … we can allocate enough. That's the beauty,” explained Tedros, who at the time of the interview said WHO moved $58 million in core funding to its health security work.
More on polio eradication:
Important public health functions, such as surveillance and routine immunization in polio-affected countries, meanwhile, have often relied on funding from WHO’s polio program, funded by the Global Polio Eradication Initiative. But in the investment case, these functions are expected to be gradually absorbed and funded from WHO’s base budget.
“This is really about maintaining core public health functions that should have been always part of the WHO budget. By bringing [it] to the WHO budget, we’re signaling to the whole world that we are ready to take on these core functions and continue to fund that,” Hollo explained.
The decision comes amid talks of GPEI winding down, as the world comes closer to eradicating the disease. There are only three countries — Afghanistan, Pakistan, and Nigeria — where polio remains endemic. But the last mile is often the most difficult.
Polio vaccination coverage continues to face challenges in areas where extremists such as the Taliban perpetuate misinformation and violence to disrupt vaccination. This has dampened advocates’ hope to stop the circulation of wild polio virus in 2018, leading the polio oversight board to prepare a new strategic plan covering 2019-2023. The goal is still to reach eradication as soon as possible, but given the uncertainties, the board is working on a budget which will be formally presented before member states at the World Health Assembly in May 2019.
With this, Hollo expects WHO to have the same level of funding for polio eradication at least for the next two years. He also told Devex that, for now, that meant maintaining WHO staff working on polio eradication, particularly in the Africa region, who were initially at risk of losing their jobs.
The investment case only demonstrates the finances needed to deliver WHO’s programmatic goals. Future WHO budgets will still be based on member states’ approval. The extent of that approval will become apparent in May 2019, when member states decide on WHO’s next budget for the biennium 2020-2021 during the World Health Assembly.
The fundraising plan
In interviews, Tedros has repeatedly expressed the need to remodel the way WHO raises funds.
“We cannot really raise enough funding using the existing model. So with the new strategic plan, we need a new model,” he told Devex in February.
What does WHO plan to do differently to raise the necessary funding for its work, as well as global health in general?
More on funding WHO:
Broadening the donor base is not a new concept, but Tedros said it was important to help WHO absorb any shocks in case some donors withdraw their funding. The organization has seen some success in the past three months, attracting new donors including the United States-based St. Jude Children's Research Hospital.
The nonprofit pediatric treatment and research facility focuses on childhood cancer and other life-threatening pediatric diseases. The center is the first WHO collaborating center on childhood cancer under the WHO Global Initiative for Childhood Cancer announced in September, and it has committed $15 million for the initiative.
“We are putting efforts in engaging new foundations, and hope to see the results of these efforts during the time frame of our new five-year strategic plan,” Hyde said.
In September, Tedros enlisted philanthropist-humanitarian Ray Chambers as an advocate for WHO’s global health agenda. A key part of his role is to raise awareness about WHO’s work and advocate for resources for global health, as he did when he was U.N. special envoy for financing the health-related Millennium Development Goals.
“There should not be ‘us’ WHO and ‘them’ donors in mobilizing the resources … we all have committed to the Sustainable Development Goals, [and] under the SDGs, the SDG 3 belongs to all of us, to the global health actors.”— Tedros Adhanom Ghebreyesus, director-general, WHO
Hyde said WHO is currently in talks with donors on potential innovative financing mechanisms, and looking at what can it learn from other organizations. The agency is also working on how to enable private sector financing to WHO without compromising the organization’s integrity and creating conflicts of interest. It is also developing a mechanism, a donate-type button on WHO’s website, to enable private donations, Hyde said.
In the early days of his term, Tedros talked about upsizing WHO’s fundraising unit. So far, no big external recruitment drives have taken place for this purpose, but sources involved in WHO’s financing campaign told Devex there have been some internal movements. Staff from different parts of the organization have been designated to specific roles for resource mobilization and donor relationship building. There’s also movement to improve coordination on resourcing across the organization.
Meanwhile, recruitment is ongoing for resource mobilization officers in three of WHO’s priority countries — Afghanistan, Iraq, and Mali — under its health emergencies program.
One of the organization’s critical strategies is around communication, emphasizing that global health goals and the targets set out in WHO’s impact framework are not solely WHO’s responsibility.
“There should not be ‘us’ WHO and ‘them’ donors in mobilizing the resources … we all have committed to the Sustainable Development Goals, [and] under the SDGs, the SDG 3 belongs to all of us, to the global health actors. So we should work together to mobilize the resources,” Tedros told Devex.
The chief way to mobilize such resources, Tedros and his predecessors have long argued, is to making funding flexible.
Currently, earmarked voluntary contributions cover 75 percent of WHO’s budget, leaving financing disparities between programs and little wiggle room for the institution to distribute funding as needed.
Former WHO Director-General Margaret Chan requested a 10 percent increase in assessed contributions, which are flexible in nature, in her last budget negotiation before stepping down in 2017. But member states only agreed to a 3 percent increase.
“I would settle for just no increase, if the quality [of funding] could change significantly.”— Tedros Adhanom Ghebreyesus, director-general, WHO
Tedros said some countries, such as Sweden, Norway, and Denmark, have responded positively to the call for more flexible funding. If this continues, he said he’d be open to having no increase in WHO’s budget.
“I would settle for just no increase, if the quality [of funding] could change significantly ... meaning if it's flexible funding and something that we can use based on our priorities and something that comes in big chunks instead of more than 3,000 grants,” he said.
This is particularly crucial in cases of emergencies, as in the current Ebola outbreak in the Democratic Republic of the Congo. WHO’s Contingency Fund for Emergencies is the organization’s quick resource to respond in case of disease outbreaks and health emergencies.
Germany, the biggest donor to the fund, has called on others to match or, better yet, "outpace" its contributions to the WHO's Contingency Fund for Emergencies.
This year alone, WHO has tapped the fund to mobilize response to 27 events in 28 countries as of October 2018. But since its creation in 2015, the contingency fund has not reached its $100 million capital target. To date, it has secured only $75 million, including the $29.5 million it received this year that already covered the bulk of funding CFE released in 2018, worth $25 million. It also has a small list of donors — just 17 in all — that does not include the U.S.
Internally, WHO has been reducing inefficiencies and cutting costs such as on travel and procurement — with savings going toward the budget, Hollo said. This included introducing much stricter criteria on business class travel, which came under fire in the wake of an AP investigation.
The sweeping rules align WHO with U.N. policy, and according to the WHO director, has led to more than 50 percent fewer business class tickets purchased in the second quarter of 2018. Total savings in 2018 from this policy alone is projected at more than $9 million, Hollo added.
Hollo said early feedback on the investment case was “extremely positive.” At October’s World Health Summit in Berlin, Germany, the German ministry of health announced new contributions to WHO amounting to 115 million euros ($130.4 million) over the next four years in voluntary contributions. While that funding is not entirely flexible, the bilateral donor has “relaxed” its earmarking criteria, providing a higher degree of flexibility for the funding, Hyde said.
“If you don’t have ambitions and you don’t state your ambitions, then you’re never going to achieve them.”— Imre Hollo, director for strategic planning, WHO
One of the things WHO is learning in dialogue with member states, Hyde said, is the significance donors place on visibility. Donors want to be recognized for their contributions and highlight synergies for joint collaboration and achievements, be it on global health security, universal health coverage, or sexual and reproductive health and rights.
This is something a number of organizations, including U.N. agencies such as UNICEF, have been doing for years. WHO has now followed suit, taking action on several fronts including by having dedicated pages highlighting partnerships with donors on its website.
But donors are also concerned about the viability of WHO’s plans, something that has been raised before and will likely be raised again at the executive board meeting in January.
“Some are saying that we’re maybe a little bit too ambitious, [asking] whether we will be able to fundraise the resources that are needed,” Hollo said. “We always say that we’re quite optimistic about our goals, and of course, if you don’t have ambitions and you don’t state your ambitions, then you’re never going to achieve them.”
Hollo stressed that the goals of WHO’s 13th general program of work are “fully aligned” with the implementation of the SDGs, and thus are “just as ambitious as the SDG goals.”
Achieving the targets laid out by WHO will only be successful when “others contribute based on their responsibility and based on their competitive advantage,” Tedros said.
So far, Hollo said he’s not heard any member states suggesting WHO revise its stated budget requirements for the next five years because they are “unrealistic.” But member states have different views, and, often, questions or disagreements come up during budget negotiations at the executive board and during the World Health Assembly.
Is there a plan B should upcoming and future budget negotiations go amiss?
“I could ask them back, ‘what is the member states' plan B?’ I mean, what we really would like is that the SDGs are achieved. So is there a plan B on not achieving the SDGs? Is there a plan B on underachieving these very important goals?” Hollo said.
“It's very difficult to say that, ‘OK, if the budget is not approved, then we're not going to do emergencies,’ or that, ‘we're not going [to do] maternal or child health.’ WHO's mandate is too complex to very simply say that certain areas will be dropped. Obviously we will need to have a very thorough look at what is possible and what is not possible. But I hope that this will not have to be the case,” he added.