WHO is in crisis. Unless member states can be persuaded to “untie” their donations and give the organisation leeway to control its budget and set priorities WHO will slide further into irrelevance with disastrous consequences for global health, warns David Legge
A substantial shortfall in the funds available for basic administrative functions led WHO’s director general, Margaret Chan, to initiate another reform of the WHO in 2010. Although the reform programme has expanded to include priority setting, governance, and management,1financing is the fundamental problem. The process of reform is also bedevilled by the same problem that led to the funding crisis in the first place—a switch in power from the assembly of member states to donors (including some member states as well as other donors) with specific interests. This article outlines the problems and what the reforms are trying to achieve.
When WHO was formed in 1948 its main funding came from its member states, who paid according to the size of their population and economy (their “assessed contributions”),2 but since its founding the large rich countries (the United States in particular) have sought to control WHO’s agenda by restricting its funding.3 Since the 1980s assessed contributions have been frozen, and the WHO has become increasingly reliant on voluntary contributions from member states, intergovernmental bodies, and various philanthropists. Assessed contributions as a proportion of total revenues have declined from 80% in 1978-79 to 25% in 2010-11. The budgetary gap has been met through the growth in voluntary contributions, 91% of which are earmarked for particular projects and programmes. As a consequence, WHO’s work is controlled by the donors rather than by its assembly of member states, distorting priorities and the coherence of its programmes.
Success of the current reform programme depends on resolving the contradiction between member state priorities and donor control and requires the freeze on assessed contributions to be lifted. To achieve this, member states must be persuaded to prioritise global health over parochial interests.
Global health crisis requires a strong and effective WHO
Despite good population health in richer nations and regional improvements in some millennium development goals, large populations continue to experience high child mortality (121/1000 live births in sub-Saharan Africa); appalling maternal mortality (500/100 000 live births in sub-Saharan Africa); malnourishment (32% of under 5s underweight in South Asia); and lack of access to clean water (39% in sub-Saharan Africa).4 The indicators are stark, but the solutions are complex: they require action at the local, national, and global levels to achieve decent healthcare, social and economic development, good governance, and an equitable and sustainable global economy.
A strong and effective WHO is a necessary condition for the global health crisis to be addressed. WHO has a unique place in global health because of its visionary constitution,5 which affirms a social view of health and health as a human right. It provides a forum, a resource, and an instrument to help national health authorities discharge their responsibilities for health.
WHO’s advice is trusted because of its technical expertise, its breadth of vision, and its accountability to national governments. By contrast, corporate philanthropy has no accountability; international financial institutions are tied to the interests of their shareholders; and global health initiatives work in narrow, vertical programmes. The 3×5 initiative6 is an example of WHO at its best, accelerating global uptake of antiretroviral therapy and holding national governments accountable while complementing (rather than competing with) bilateral and multilateral mechanisms to fund the roll-out of treatment.
WHO’s treaty making powers are another unique asset. Although these powers have been used only twice (the International Health Regulations and the Framework Convention on Tobacco Control), rising globalisation and the increasing power of global corporations create a strong case for the wider application of these powers.7
WHO’s budgetary and organisational disabilities
WHO’s capacity to provide the necessary leadership and drive is compromised by serious budgetary and organisational disabilities, including donor dependence, contradictions in human resource management, excessive decentralisation, and lack of accountability on the part of member states for their custody of this critical global institution.
WHO has been seriously weakened by the progressive loss of control by the World Health Assembly, the assembly of member state delegates, over its budget and work plan. The formula for assessed contributions, which WHO can spend as it wishes, has been frozen since 1982 (box) after US opposition to WHO’s essential drugs policy89 and the code for the marketing of breast milk substitutes.10 As a result, WHO is now largely dependent on voluntary contributions, earmarked for specific purposes, from a variety of state and non-state donors. This makes it hard to follow the agenda of the member states, as expressed at the World Health Assembly.
How WHO is funded
WHO’s main budget is funded through mandatory assessed contributions by member states and voluntary contributions (from member states, other intergovernmental bodies, and private foundations)
Assessed contributions, the spending of which is untied, totalled $945m (£590m; €734m) in 2010-11.11 The amount paid is based on a country’s population and GDP using a formula fixed in 1982
Voluntary contributions comprised around $2898m in 2010-11, of which $248m was untied and $2649m was earmarked for projects chosen by the donors
The five member state donors making the biggest voluntary contributions in 2010-11 were the US ($438m, 100% tied), UK ($289m, 84%), Germany ($189m, 100%), Canada ($182m, 100%) and Norway ($114m, 58%)12
The proportion of WHO’s revenue gained from assessed contributions has fallen from 80% in 1978-7913 to less than 25% in 2010-1111
Assessed contributions are drawn on to supplement funding provided through donor grants because many donors refuse to pay the full cost of overheads
A major study of WHO financing in 1995-96 pointed out that the voluntary contributions were overwhelmingly directed at disease prevention, with health systems virtually ignored.13 Stuckler and colleagues calculated that in 2006-7, WHO allocated 87% of its total budget to infectious diseases, 12% to non-communicable diseases, and less than 1% to injuries and violence.14 The pattern of allocation was the same in Africa, which has a high burden of infectious disease, as in the Western Pacific region, where three quarters of mortality is from non-communicable disease.
The relation between trade and health also shows how donors affect priority setting. Availability of affordable medicines is threatened by increased intellectual property protections, restrictions on the use of compulsory licensing, and constraints on price setting in government pharmaceutical reimbursement schemes introduced as part of new regional and bilateral trade agreements.15Wider use of “investor-state dispute settlement” provisions (ISDS) in trade agreements place powerful new weapons in the hands of the tobacco, food, alcohol and many other industries to resist public health regulation. These provisions give foreign investing companies the right to sue governments when their regulatory policies reduce the value of their investments.16 Tobacco manufacturers’ attempts to use ISDS provisions to prevent the Australian government from mandating plain cigarette packaging (although in this case unsuccessful) illustrate how ISDS may be used as a barrier to effective regulation.15 WHO has been promising a new tool to assess the health effect of trade agreements for the past four years but has not had the funding to produce one.
The reliance on donor funding has also raised questions about conflict of interest. At the World Health Assembly in May there were repeated calls for WHO to adopt more robust protocols for dealing with institutional conflicts of interest—for example, in relation to the pharmaceutical and food industry.717 Yet the power these industries exercise over the secretariat is partly mediated through the advocacy of the member states who host large transnational corporations, notably the US, Japan, and Europe.
WHO’s regional directorates exercise an unusual degree of autonomy (compared with their counterparts in other global intergovernmental organisations), reflecting the compromise that was needed to persuade the Pan American Health Organisation to join WHO in 1948.18This historical decentralisation has intensified as a consequence of donor dependence, as regions embark on parallel and competitive fund raising—in effect, selling their products to the donors. Under such circumstances senior managers are accountable to “their” donors rather than to a coherent organisational strategy set by member states. This degree of decentralisation fragments the organisation, jeopardises programme coherence, and weakens accountability.19
Another set of challenges (which is common to all UN agencies) comes from staffing practices. Challenges here include achieving a balance of staff nationalities while ensuring appointments are based on merit; staff mobility (valuing specialist expertise in headquarters as well as assuring high quality staff for country offices); and conditions of employment (balancing workers’ entitlements with management flexibility). These tensions all influence the quality of advice and support that WHO can provide to countries. There are no simple remedies; the human resource environment in which WHO operates is changing all the time and staffing policy will also need to evolve if it is to remain suited for purpose.
Member state accountability
Both the secretariat and member state representatives often repeat the statement that WHO is an intergovernmental organisation, driven by member states. However, delegates and health ministries have only limited accountability for how they govern WHO and for their contribution to the objectives set out in the constitution.
Delegates often come to the assembly without having read their papers or fully considering the issues. Speeches often bear only limited relation to the issues under discussion. The positions adopted by many of the big powers in WHO are sometimes more directed at protecting the interests of their transnational companies than promoting population health.
Programme of reform
Margaret Chan’s attempt to tackle these challenges is made doubly difficult by the fact that the reform programme suffers from many of the problems that need to be tackled. Some progress is being made in all areas, but financing remains the central issue. Chan made it clear in May 2011 that her preferred option would be increased assessed contributions. 20 Once it became clear that this was not going to happen in the short term, her fallback position has been “stable and predictable financing.” She has urged donors to untie their donations—or at least to tie them at the highest level of budgetary allocation—to give the organisation greater flexibility in responding to the agenda of member states. In fact, four of the top 10 member state donors21 (US, Japan, Canada, and France) do not give any untied voluntary funding.12
As this was also met with a lack of enthusiasm she has argued for a more cooperative, transparent, and centralised process for negotiating funding for the priorities agreed by member states. She has proposed various organisational models for achieving this objective, the latest of which is a “funding dialogue.” However, member states are concerned that this will institutionalise the control of the donors.
Particularly controversial at the May 2012 World Health Assembly was the timing of the funding dialogue in relation to the meetings of WHO’s governing bodies. At present the funding dialogue is scheduled for the first quarter of the calendar year, after the January meeting of the executive board and before the World Health Assembly in May. Under this arrangement the executive board will adopt a draft budget in January, and donors will then be asked to fund various elements. The outcomes of this funding dialogue will then come to the assembly in May, where member states will be invited to accept the budget as funded (or adopt a different, unfunded, budget).
Some observers are hoping that Chan will take advantage of her second and final term of office to confront the rich states who refuse to accept an increase in assessed contributions. She could find some support in the governing bodies. However, the decision to starve the organisation into obedience by freezing contributions is not taken by the member state representatives, who are generally career public health people and supportive of policy coherence across trade and health, but by politicians and bureaucrats in the capital cities of rich nations, where economic and foreign affairs portfolios hold sway and corporate stakeholders lobby against any loosening of the leash.
Member states who oppose increasing assessed contributions or the untying of their donations advance two main arguments: firstly, that WHO needs to attend to problems of efficiency and effectiveness before funding is revisited and, secondly, that WHO should live within its means through better priority setting. The paradox is that the shortfalls in efficiency and the problems of programmatic incoherence are largely the consequences of the donor chokehold.
While priority setting has been a leading theme in the discussions of reform, a robust methodology for doing so is lacking.22 The director general has promised that the “cross cutting issues” (social determinants, gender equity, human rights, and primary healthcare) will not be neglected, but no clear procedures have been advanced for ensuring this or for working across silos generally.
The reform package (box) is at its weakest in relation to member state accountability. Indeed, the concept has not been identified as a problem in any of the official papers prepared by the secretariat. However, there have been some minor initiatives directed at streamlining discussion at governing body meetings and providing better briefings for member states.
Funding dialogue—a more cooperative, transparent, and centralised process for negotiating funding for member state determined priorities plus an appeal to donors to untie their donations
Priority setting—new categorisation of programmes and a new approach to priority setting based on the problems identified in country cooperation strategies
Governance reforms—includes a review of the sequencing of governing body meetings; aligning the work of regional committees more closely with that of the executive board; harmonising the procedures of regional offices; streamlining governing body meetings; and clearer policy development around relations with stakeholders
Managerial reforms—includes staffing practices, clearer conflict of interest policies, improved evaluation, and a more strategic approach to public relations
There is no clear endpoint that would define the completion of the reforms. Some progress will be made on some of the issues. Debate will continue on others. Currently, the regional committees are meeting and discussing the full reform package. In early December there is a closed meeting of member states to further consider reform in the budget process.
However, there is a serious risk of stalemate. If member states are not willing to address the root problem of donor dependence and lack of flexible finance, WHO will slide further into irrelevance, with disastrous consequences for the global health crisis. Paradoxically, the unnamed disability—the lack of accountability of member state representatives and the limited engagement of civil society in holding WHO to account—may provide the most promising strategy for driving successful reform. Public health advocates need to make rich countries accountable for privileging corporate interests over global health. In low and middle income countries governments must be persuaded to agree in advance to increasing assessed contributions so that their representatives can speak with authority regarding the need for adequate untied funding. Organisations such as WHO Watch (www.ghwatch/who-watch), which has been working to build stronger links between international decision making at WHO’s governing bodies and grassroots networks addressing local and national needs, could help to strengthen WHO and member state accountability.
Cite this as:BMJ 2012;345:e6877
Contributor and sources: DL teaches health policy and comparative health systems at La Trobe University in Melbourne and is academic coordinator of the International People’s Health University—a short course programme for health activists presented through the People’s Health Movement. He is also involved in WHO Watch.
Competing interests: The author has completed the ICMJE unified disclosure form atwww.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; externally peer reviewed.