Post date: Wed, Aug 5, 2020
Category: Health
By: Emmanuel Wa-Kyendo,

By: Emmanuel Wa-Kyendo

Introduction

The World Health Organization (WHO) is an intergovernmental public health agency. Formed on 7 April 1948, the WHO is a part of the wider United Nations Sustainable Development Group . The organization’s goal is to ensure the highest state of health for all the citizens of its member states. The functions of the WHO reflect those of a typical public health institution. Disease surveillance and research efforts are an important part of its activities and it is well known for its efforts to eradicate measles and polio. The WHO is also sanctioned by its member states to declare pandemics and give names to unknown diseases. In a sense, the WHO functions like a think tank on diseases with a special concern or for those with global implications.

What follows is an analysis of the latest WHO budget. An organizations budgetary allocations are an important indication of its priorities. I posit that the same is true for the WHO. I assess the four major budget lines, the WHO’s important programmatic focus in this budget cycle, and the WHO’s sources of financing. The WHO’s programmatic focus is termed the ‘Triple Billions’. I explain what these objectives are and where they fit in the budget.

Table 1: WHO Program Budget Figures for Financial Periods 2018-2019 and 2020-2021 (US$ Billion)

As illustrated by table 1 above, the WHO adopts a biennial budgeting and expenditure cycle, meaning that budget numbers above account for two calendar years. The total allocation for 2020-2021 of $US 4.84 billion represents an 8% increase in value over the previous biennial cycle. For purposes of scale, the Kenya’s Ministry of Health spent about US$2 billion in the financial year 2018/19 . The Ministry of Health provides services for a nation whose citizens number 47 million. The World Health Organization’s work caters for a limited slate of the health concerns of just about 7 billion people but is different from a health department because it is not organized to provide direct health services to the world’s population. Where Kenya’s healthcare budget amounts to about $40 per person per year, the WHO spends less than 1 US$ per person based on the total population of its member countries. The WHO is neither designed too nor equipped to provide health services that a national public health system would.

The budget is divided between a base segment, polio eradication and special programs. The Base budget has accounted for more than 75% of total allocations for the latest budget and the previous biennial budget for the years 2018-2019. The Base segment of the budget is allocated towards building the WHO’s technical capacity and moving the WHO away from polio eradication towards general healthcare system objectives. Though surveillance, immunization, disease containment and health emergency response has only recently entered the common lexicon, these general public health objectives have been a key component of the WHO’s programmatic efforts.

For the financial cycle starting in 2020, $1 billion has been allocated between the Polio Eradication Program and Base element of the budget will be allocated towards the eradication this disease. The full control of measles was one of the WHO’s and the United Nations’ most significant achievements. Efforts to eradicate Polio are now focused on pockets of the world where the disease persists. These efforts have flagged because of local resistance to vaccination, to name one obstacle. Fluctuations in funding to the WHO to keep pursuing this goal would threaten these efforts.
Table 1 shows that the US$90 million increase in funding for the special programs budget line was reallocated from the Base budget. The Special Programs budget line denotes funding to be allocated towards three special programs namely;

1. Special program of Research, Development and Research Training in Human Reproduction (HRP): The HRP is the principal human reproduction research organ within the United Nations system. The WHO is among five co-sponsors of the HRP. Co-sponsors make regular budgetary contributions to this organ. Other sponsors are the World Bank, the United Nations Children’s Fund  (UNICEF), United Nations Development Program (UNDP)  and the United Nations Population Fund (UNFPA).
2. Special Program for Research and Training in Tropical Diseases (TDR): The TDR is a program that unites scientists in collaborative work to provide technical support, facilitation and influence in the realm of specific poverty related diseases. The WHO is cosponsor of this program. Other co-sponsors include the World Bank, the United Nations Children’s Fund (UNICEF) and the United Nations Development Program (UNDP) .
3. Pandemic Influenza Preparedness Framework: This program is designed to bolster global influenza preparedness by augmenting the WHO global influenza surveillance and response system (WHOGISRS). This program’s objective is to promote equitable distribution of influenza preparedness measures among member states. Specifically, the program facilitates the exchange of information on H5N1 and other influenza viruses, vaccine access and other facilities .

The Special Programs budget line saw the largest upward revision in relative terms. This may be due to an increase in demand for resources to fund the COVID19 emergency response.

The Triple Billions, 2020 – 2023

Launched in 2010 to be achieved by 2023, the Triple Billions objectives belie a desire to shift the organization towards the support of public health systems development. The latest WHO General Plan of Work has set four objectives to be met in the next two years. These objectives do not have their own budget lines. Rather, they are interwoven within the Triple Billions objectives. They are designed to support and be a part of the Triple Billions objectives. What follows is an assessment of these objectives and their implications for the work of the WHO.

Objective 1: a drive towards measurable healthcare impacts

Firstly, the WHO has emphasized a drive towards measurable healthcare impacts. Measuring healthcare impacts requires setting scientific standards of measurement. As these healthcare impacts will be measured at the national level and then the global level, the WHO must standardize these measures at the global level. These measures will govern information collection, processing and analysis. These efforts will themselves be framed within monitoring, surveillance and reporting mechanisms that must be coordinated at the global level. Cooperation at this scale will require transparency and non-interference. In order that this objective be met, stakeholders will require training and equipment.

Objective 2: A Drive Towards Demonstrating Alignment of Resources with Impacts

The members of the United Nations (UN) and the WHO in particular expend an important amount of public resources to fund these institutions. In the management of scarce resources, the monitoring of causes and effects of budget allocations is an important principle. It is this monitoring that can reveal whether a program exists only in rhetoric or is followed by resource allocations and activities. After that is established, the effectiveness of resource allocations, activities and the programs themselves can be properly assessed. Lastly, aligning resources with impacts is important when these impacts are expected to aggregate into a United Nations global objective.

Objective 3: A drive away from disease-specific approaches and towards efforts to bolster whole healthcare systems

This objective is in keeping with the small resource allocation size of the WHO and the organizations desire to build sustainable health impacts. The WHO’s small budgets leave it playing an advisory role in global emergencies and leave room for limited interventions in particular circumstances. There is only so much that can be done with $4 billion. This renders the objective a prudent one. Furthermore, the drive away from disease-specific approaches implies an institutional migration away from the frontlines of intervention and further into an advisory role. It is by directing efforts into public healthcare research and development at the national level that the institution will support the advancement of healthcare systems in a sustainable way. This effort will be augmented by the organizations work in instituting measurable solutions.

Objective 4: A Drive Towards Synergizing Efforts Throughout the Three Levels of the Organization

The WHO is divided into headquarters, regional offices and country offices. These are the three levels referred to in this objective. At a glance, this drive seems to be supported by with the efforts to institute measurable healthcare impacts, align resources and support the advancement of healthcare systems. Synergy implies that the WHO acts at the granular, localized level, receives and transmits feedback up through its chain of command and then expresses new actions from the center downwards again. It is also arguable that this objective is an expression of a desire to raise WHO responsiveness by merging facts on the ground with WHO direction. This objective also bellies a desire to have the WHO articulate the United Nations objectives in a manner that reflects the realities, objectives and institutional constraints.

Table 2: Comparison of Program Budget 2020-2021 by Strategic Priority

Source: WHO Programme Budget 2020 – 2021

The triple billions objectives represent an important shift in the structure of WHO activities. These objectives were introduced in March 2019. The billions in this term refers to one billion people. One billion people are not exclusive of each objective.  Where the WHO was focused on specific diseases in the past, these objectives are related to moving the organization towards systematic contributions to health systems of nations the world over. These objectives are designed under the theory of change framework, which allows activities to match efforts with measurable results . It is this approach that the WHO employs to set these targets and report progress with a dynamic dashboard visual on the web.

Triple Billions Budget Distribution by Region

Source: WHO Program Budget 2020 – 2021

Though this analysis focuses on the WHO budget and its functional distribution, a glance at regional distributions reveals that the organization does have regional allocation priorities.  In addition to its headquarters in Geneva, the WHO operates 6 regional offices and 150 country offices. The country offices report to the regional offices. Regional offices are semi-autonomous units. WHO budgets are split between the Headquarters, regional offices and country offices. As the chart above illustrates, the typical split gives the country offices the larger portion of the budget. WHO headquarters also commands an important share of the budget. As illustrated above, the African and European regions received the largest and smallest shares of the triple billions budget. According to the World Bank, in 2018, the European Union alone had a GDP of US$15 trillion and a population of 446 million people. Sub-Saharan Africa’s GDP was US$1.714 trillion for just about 1.078 billion people. In that year, Sub-Saharan Africa was less productive than Europe. From this illustration, the poorer region got the larger share of the budget. This is not to say that the budget allocations are necessarily related to economic productivity. In the face of a public health emergency, wealthier nations may be in a stronger position than their poorer counterparts. WHO regions are as follows;

1. Africa
2. Americas
3. South-East Asia
4. Europe
5. Eastern Mediterranean
6. Western Pacific

The Triple Billions Objectives

The term triple billions refer to the WHO objective to ameliorate the health of a billion people or more by 2023. This objective is not mutually exclusive. Each objective will not cover a separate set of billions. Rather, there will be overlap. Together, the triple billions objectives make up the base segment of the budget discussed above. That segment is $3.7687 billion in size. The triple billions objectives are;

1. B1: One billion more people benefitting from universal health coverage
2. B2: One billion more people better protected from health emergencies
3. B3: One billion more people enjoying better health and well-being.

These three objectives will be supported by a fourth

4. More effective and efficient WHO better supporting countries

TRIPLE BILLIONS B1: Universal Health Coverage (UHC)

The universal health coverage target calls for providing universal healthcare to 1 billion people by 2023. The WHO estimates that by 2019, 58 million people had universal health coverage. The organization estimates that by 2023, 291 million people will have universal health coverage. That is, the world will have met 29.1% of its objective. This will be off the mark by an excess of 700 people.

Universal Health Coverage (UHC) Budget

In 2020-2021 biennial cycle, the UHC objective have been allocated US$1.358 billion, with the WHO headquarters and Africa allocated 30% and 26% share, respectively. These two offices received the largest share of WHO funds. In 2019, 58 million people had been reached . The WHO itself projects that at this pace it will reach 291 million people or 29.1% of the target by the year 2023. By their own implicit admission, the WHO is behind its UHC objectives .

This budget will be allocated to meet the following three outcomes:

a.    Improving access to high grade essential health services
b.    Reducing health related financial hardship
c.    Increasing access to essential health products and services in primary healthcare.

Objective a: Improving Access to High Grade Essential Health Services

The term essential health services refers to vaccines, medicine and healthcare that is safe, effective and of a good quality. Access to health services is predicated on economic endowment. A person can only have the healthcare services afforded to them by income or subsidized by an external entity. This objective reflects the United Nations (UN) sustainable development objective 3.8 which imputes the achievement of holistic health coverage. The WHO and the UN are both of the perspective that in addition to bolstering health system development, the public that is bound to access that system should also be empowered with the wherewithal to do so.

Objective b: Reducing the Number of People Suffering Financial Hardships

800 million people suffer the effects of economic hardship inflicted by medical payments. The United Nations estimates that almost 100 million of these people pushed into extreme poverty. The WHO has determined that there is a need to address this problem. The WHO will leverage its resources in instituting the changes it believes will alleviate the financial burden inflicted by medical payments. The secretariat will support member states in adapting budgets, designing medical sector objective and designing medical financing solutions that cater to those with irregular incomes.

Objective c: Increasing Access to Essential Health Products and Services in Primary Healthcare

The WHO intends to support efforts to raise essential healthcare access by providing a thorough standards regime. This regime will cover measures that ensure a standard quality, safety and efficacy of health products. The WHO will also leverage its technical resources in an effort to institute transparent, corruption free and effective procurement and supply. Lastly, the WHO will work to support the streamlining of national regulatory procedures with a global standard. The idea here is that affordable and effective medicines should flow from supply to demand with the greatest ease possible and at the global and national levels.

TRIPLE BILLIONS B2: Global Health Emergency Protection

The second triple billions objective is to provide one billion more people with protection against health emergencies. The WHO estimated that By 2019, 193 million people were already privy this protection. The organization estimates further that by 2023, only an additional 516 million people will have been targeted. That is to say that by 2023, the objective will have been met by 51.7% . This will be off the mark by 500 million people.

Global Health Emergency Protection Budget

In 2020-2021, the WHO will allocate $US 888.8 million towards global health emergency protection.  WHO Headquarters and Africa will receive 25.1% and 32% of this share, respectively. These two sections each receive the largest shares of all sections. The WHO projects that it will meet 51.7% of its objective or 516 million people by 2023 . This will be off target by 266.77 million people.

B2 Objectives

The three outcomes sought are:
a.    Improve health emergency preparedness among member countries
d.    Prevent epidemics and pandemics
e.    Surveillance, detection and timely response to health emergencies.

Objective a: Improve Health Emergency Preparedness among Member Countries

WHO member states have an obligation to implement public health threat preparedness measures. These measures were decided by the consensus of WHO member states. The agreed upon consensus was established around focal points selected at the national level. These focal points are supported by health emergency monitoring, surveillance, detection and notification mechanisms, information exchange and transparency measures. Training, simulation exercises, after action reviews, annual reports and voluntary joint external evaluations also number among measures designed to improve health emergency preparedness among member countries.

Objective b: Prevent Epidemics and Pandemics

From the perspective of the WHO, COVID19 is only the latest global health emergency. The institution has led its member states in responding to other emergencies. The measures that contribute to this triple billions objective have been tested in real global health emergencies and reflect the WHO’s experience, therefore. COVID19 demonstrates the potential social, political and economic magnitude of public health emergencies at the global scale. Meeting this objective is critical to the social, political and economic welfare of the people of the world.

Objective c: Surveillance, Detection and Timely Response to Health Emergencies

The quality of response to global health emergencies is at least partly dependent on the quality of surveillance and detection mechanisms. Because infectious diseases can occur anywhere at any given time, the WHO must institute surveillance and detection measures that are relatively comparable irrespective of the particular member state. Conceivably, the WHO measures will have a minimum threshold to be met by implementing member states. Lastly, all things equal infectious diseases are an equal opportunity threat. One nations problem quickly becomes another nations problem. It is therefore in the interest of member states to meet these measures.

TRIPLE BILLIONS B3: One Billion More People Enjoying Better Health and Well-Being 

The third triple billions objective is to raise the number of people enjoying better health and well-being. This is to be achieved by targeting the determinants of and the risks to health. These risks and determinants exist within the environment, in the foods consumed and in the activities in which people engage. These determinants include consumption of food, sanitation, environmental sustainability and safety on the road for both drivers and pedestrians.

Trible Billions B3 Budget

The WHO will allocate $US 431 million towards this objective. WHO headquarters and Africa will receive 28.97% and 25.86% shares of this allocation, respectively. These two sections each receive the largest shares of all office sections . Africa’s share will be 2.3 times larger than that of Europe. This objective has seen positive results among 124 million people by 2019. The WHO projects that it will meet 61.9% (619 million people) of its own targets by 2023 . This will be off target.

B3 Objectives

The healthy populations objective calls for driving healthier outcomes for one billion people and has the following outcomes:

a.    Addressing the determinants of health
b.    Addressing risk factors through multisectoral actions
c.    Healthy settings and health in all policies promoted

Objective a: Addressing the Determinants of Health

The WHO conceptualizes the determinants of health throughout a person’s life as existing within socio economic and political structures. Climate change is also recognized as an important determinant of health. These structures have an effect on the wellbeing of individuals. The WHO will address determinants through its institutional expertise. The WHO believes it can best support this through a mix of approaches that include advocacy, multi-sectoral and multi-agent coordination, suggesting public health norms and standards and the production of data products related to the determinants of health.

Objective b: Addressing Risk Factors through Multisectoral Actions

In support of this objective, the WHO will target factors whose risk to health can be reduced. The objective here will be to raise health and reduce mortality rates. The risks to be addressed include lack of mental health, alcohol, tobacco and drug abuse, lack of exercise and the maintenance of unhealthy dietary regimes. Agricultural, financial and the education sectors are just a handful of examples of the diverse sectors that the WHO believes must be rallied to help meet this objective.

Objective c: Healthy Settings and Health in All Policies Promoted 

In pursuit of raising health and wellbeing, the WHO will also work to engage municipalities and other spaces (households, schools, places of work, prisons etc) and multilateral interfaces. The WHO will address the capacity of municipalities, the wider government and society to institute mechanisms that ameliorate factors that raise health and reduce the risk of factors that are harmful to health. The WHO will engage with this community based networks and then encourage and support them to take part in public decision – making. The idea here is to make positive health practices well known and pervasive throughout society.

Multilateral engagements will be geared towards bolstering multi sectoral challenges and reinforcing the maintenance of international public health instruments. All in all, the idea here is to engage whole governments and their local, grassroots and international partners in deliver public health goods in a society pervading manner.

The WHO will leverage its data and standard setting expertise in support of this objective.

More Effective and Efficient Who Providing Better Support To Countries

Accurate data collection and dissemination is central to assessing progress against resource allocations and making informed decisions. The WHO will leverage its data and information proficiencies to support member states in building robust information processing, monitoring, surveillance and reporting systems. Robust in this case means that these systems will allow the countries to measure their progress towards Triple Billions objectives and the United Nations Sustainable Development goals. The implementation of standards and norms across member states is dependent on this objective. It is notable that the WHO will allocate 29% of its base budget or US$1.090 billion on this objective. This is a strong signal of the emphasis the WHO is now placing on research.

Chart 1: 2018 WHO $2.160B, Budget Revenue Sources, 2018 only

Source: World Economic Forum

The WHO classifies its primary revenues into assessed contributions and voluntary contributions. Assessed contributions are specified amounts paid by the governments of member states, relative to their income and population. This is a membership fee. Voluntary contributions are unspecified amounts paid by the governments of member states, private interests and private individuals. As the name implies, these contributions are made on a voluntary basis. Voluntary contributions are made with specific stipulations as to how they are to be deployed. As explained in the first chapter, the WHO budget is approved for two years ahead.

In 2018 alone, the WHO received US$2.160 billion. The United States’ contribution of just under $400 million in 2018 made it the largest source of primary funding for the WHO. In per capita terms, the USA contributed just above $1 per US citizen to the WHO. USA’s assessed contributions amounted to $111 million whereas their voluntary contributions were a significant $262 million.

The funding formula for the WHO requires the member states to make assessed contributions relative to their economic output and population. This formula balances economic output and per capita incomes generated. A large economy with a small population will pay a greater membership fee than an economy of the same size with a larger population. The voluntary contributions of the United States were larger than their assessed contributions. Though Switzerland has a larger per capita income, the USA makes a larger assessed contribution to the WHO than does Switzerland.

The United States also leverages its considerable public health resources in facilities and technocrats. These contributions manifest in technical support in research and project implementation.
Having made just above $200 million in contributions, The Bill and Melinda Gates Foundation was the second most important contributor to WHO funding. The other important private contributor was the GAVI Alliance that itself contributed $371 million. Furthermore, in 2018 private interests in total accounted for just 2% of the WHO’s resources.

The WHO has greater discretion in spending the allocations from the assessed contributions. Voluntary contributions are different because they must be spent in accordance with the contributors wishes. It is notable that the voluntary contributions of the United States are consistently greater than its assessed contributions.

The WHO constitution was agreed upon by the nations of the world. All its funding mechanisms were designed on consensus. Important contributions in funding signal a desire on the part of the United States and other contributors to contribute to WHO activities and conversely the collective public health objectives of WHO member states or virtually the whole world. This also signals a desire to influence WHO activities through specific priorities in health policy.. Furthermore, sizeable US contributions mean that a departure of the former would leave a markedly perceptible vacuum.

In March 2020, the WHO made a public appeal for $675 million to help shore up its efforts to combat the COVID19 pandemic. The organization opened a ‘solidarity fund’ through which the worlds private citizens, private interests and governments can contribute to COVID19 response. In April, the WHO made an appeal for a further $1 billion. The organizations’ solidarity fund remains open for all who would contribute . There is no implied restriction on amounts donated or a ceiling on how much the organization will accept.

By 27th May, 2020, the WHO had established a foundation to support its financial revenue collection objectives. Legally separate from the WHO, the foundation will receive funding from public and private sources and channel it towards the WHO. According to the Director General of the WHO, this foundation was not founded as a response to recent rhetoric from the executive branch of the government of the United States. Instead, the Director General offers that the idea for the formation of foundation has been in the works.

Conclusion 

Ambitions Outsized by its Budget

Relative to the budget of Kenya’s public health apparatus, to cite one example, the WHO budget is not quite large. And yet its primary goal of providing the highest health outcomes possible for the people of the world is titanic. The WHO is expected to serve the citizens of the whole planet while spending less per US$  than the Kenyan government .This is an organization whose ambitions are far larger than its budgets and this is a reason why the establishment of a foundation to secure its funding seems to be a sensible one.

Systematic Public Health Inputs

The organization is evolving towards supporting systematic public health inputs and away from a focus on single diseases. This is reflective of the move towards sustainability in development outcomes. The WHO might as well to transform itself into a full-fledged think tank on global health.

Budget Contributions 

The United States is the WHO’s single largest contributor. This remains true when its submissions to the WHO budget are divided between assessed contributions and voluntary contributions. Additionally, the US submits larger voluntary contributions than it does assessed contributions. This suggests a continuing desire to maintain support for the objectives of the WHO and conversely the global public health system. The WHO welcomes private individuals and organizations to contribute to its budget. The Bill & Melinda Gates Foundation is an American private foundation that is the most important private source of funding for the WHO. Private funding represents a small share of total funding, nonetheless. Today, global public health is tested by shifts in funding attitude by its most important financial facilitator. It is important to note, however, that the funds subject to withdrawal constituted voluntary contributions. It may be that the concern of WHO members is a response to the perceived spirit of hostility with which the US administration is threatening to withdraw these funds.
Withdrawal of US Funding Would be a Threat

What may complicate the funding matter is the fact that much of the WHO’s voluntary contributions do not give the WHO discretion over its expenditure. Furthermore, hostility towards the organization that is reflected in hoarding of technical resources by the USA or any other nation would have negative effects on WHO efforts to improve global health outcomes.

The WHO has instituted a new financing foundation. This represents a positive development in efforts to financially facilitate the United Nations.

References

1. France 24. (2020, April 15). Who funds the WHO?
2. Kaiser Family Foundation. (2020, April 16). The U.S. Government and the World Health Organization. Retrieved from Kaiser Family Foundation: http://www.kff.org
3. Ministry of Health. (2019). National and County Health Budget Analysis 2018/19.
4. Thomson Reuters Foundation. (2020, April 9). WHO’s new Funding Appeal For Coronavirus Fight to Top $1Bn Diplomats. Retrieved from Thomson Reuters Foundation: http://www.news.trust.org
5. World Economic Forum. (2020, April 15). How is the World Health Organization Funded?
6. World Health Organization. (2020, June 10). About. Retrieved from World Health Organization: http://www.who.int
7. World Health Organization. (2020, June 5). Pandemic Influenza Preparedness Framework for the Sharing of Influenza Viruses and Access to Vaccines and other Benefits. Retrieved from World Health Organization: https://www.who.int
8. World Health Organization. (2020, June 11). TDR. Retrieved from www.who.int: www.who.int
9. World Health Organization. (2020, June 11). TDR. Retrieved from World Health Organization: https://www.who.int
10. World Health Organization. (2020). Triple Billion Dashboard. Retrieved from http://www.who.int
11. World Health Organization. (2020, May 27). WHO Foundation Established to Support Critical Global Health Needs. Retrieved from World Health Organization: http://www.who.int
12. World Health Organization. (2020-2021). Programme Budget.

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