 Director General Tedros Adhanom Ghebreyesus during a new news conference at the World Health Organization headquarters in Geneva on Dec. 20, 2021. (Salvatore Di Nolfi/AP) | The World Health Organization saw unprecedented attention during the pandemic. Some of it has been good — there was talk of it winning a Nobel Peace Prize for its efforts — some of it was bad — fierce attacks from both Beijing and Washington alike — but it was certainly a change for a United Nations agency not used to the front pages. One thing that hasn't changed so much, however, is money. Or rather, the fact that there isn't enough. The WHO's original two-year budget for 2020 and 2021 was $4.8 billion, with another billion earmarked for emergency operations. That's a considerable amount of money — until you consider the fact that this is the world's top global health body with a near-limitless portfolio, which WHO officials never forget. On an annual basis, the original WHO budget of less than $3 billion is well under half of the U.S. Centers for Disease Control and Prevention's proposed budget for 2020. In fact, it's far smaller than the net revenue of many large hospitals in the United States. While the pandemic resulted in a surge in additional funds coming to the WHO, taking its total available funds to over $8 billion, that money is a one-off deal, tied to an emergency rather than long-term goals. The pandemic also revealed the precarious nature of the WHO budget, which comes largely in the form of voluntary funds from foreign governments and other donors. As the pandemic began, President Donald Trump announced in April 2020 he would suspend U.S. contributions amid claims WHO was "severely mismanaging and covering up the spread of the coronavirus." The Trump administration later moved to pull out of the WHO, even suggesting it would withhold roughly $62 million in funding pledged to the organization. Though Trump is gone, the concerns about WHO funding aren't. And even with new leadership, the United States remains at the center of the debate. This week, WHO Director General Tedros Adhanom Ghebreyesus said the organization could not achieve its aims without reforming the funding model. "If the current funding model continues, the WHO is being set up to fail," he told delegates in Geneva on Monday. Initially, the majority of WHO funding came from assessed fees of member states, which were scaled by income and population size so wealthy nations like the United States paid the most. However, over the past 30 years, these fees have essentially remained flat after President Ronald Reagan led a push to freeze contributions to U.N. agencies over fears they were being politicized. Faced with the difficult task of forcing governments to pay more, the WHO instead turned to voluntary funding to make up the shortfall, whereby governments could opt to make ad hoc donations. These donations now make up more than 80 percent of recent WHO budgets. The problem for WHO officials is that, unlike assessed fees which are used as they see fit, voluntary contributions from governments and private organizations are often earmarked for specific programs. These programs may be in line with national interests, sometimes with restrictive conditions, and are often short-term in nature. Supporters of reform say these restrictions create a bureaucratic mess, slowing down the WHO. "It's impossible for the WHO to recruit world-class scientists if it can't offer them a long-term future and stable contracts," Lawrence Gostin, a global health law professor and director of WHO's Collaborating Center on National and Global Health Law, told me. Last year, the WHO set up a working group to look at "sustainable financing" for the organization. One possibility the group reached was that assessed contributions should gradually increase so they would eventually comprise 50 percent of the WHO's core budget in 2029. It is currently just 17 percent. Others argue it should aim higher. "We continue to believe that funding the WHO through a substantially higher level of assessed contributions, closer to the 80 percent share of the early 1980s, is the best way forward," a group of former world leaders and global health experts wrote in a USA Today opinion article this week. But the United States is hesitant. Loyce Pace, assistant secretary for global affairs at the Department of Health and Human Services, told a WHO executive board that the United States needed to "better understand the current funding mechanisms, efficiencies and decision-making" before any new funding. U.S. officials have concurrently pushed for a new fund, separate from the U.N., that would be directly controlled by the donors and focus on pandemic preparedness and other emergencies. Discussions for the fund are still in the early stages, but it could be housed at the World Bank and involve up to $10 billion, according to reports last year. Though there are other skeptics, the Biden administration's hesitation has become a major point of contention. It holds considerable sway as it had long been the largest donor to the WHO. Now, it is at odds with many European and African nations that have pushed for reforms to WHO funding. One European official on the WHO executive board, speaking on condition of anonymity as they were not authorized to discuss the matter, said many other nations were upset about the United States pushing the idea of a separate fund. "A new structure is a sign of fragmentation," the official said, adding that there would be a lack of inclusivity if wealthy donors were given full control. With the cuts to funding under Trump, the United States' largesse to the WHO has already been overtaken. Reuters reported Wednesday that U.S. funding to the global health body had declined by 25 percent during the pandemic. Other nations increased their funding substantially during this time, with Germany now taking the spot as the top donor. A spokesperson for the HHS said the United States remained the largest donor of assessed donations, having recently provided a $280 million voluntary pledge, too, but added that the United States welcomed "recent increases in German funding to the WHO." There's no consensus on funding, but time is running out. At a board meeting Tuesday, Björn Kümmel, a German diplomat chairing the working group on sustainable financing, said that while some opposed changing the WHO's finances, others thought that the proposal was "not ambitious enough." It is likely that a decision will not be made until the World Health Assembly, scheduled to be held in May. The United States' attitude to both WHO funding discussions and a separate global agreement on pandemics are being closely watched. U.S. officials say no final decision on either has been made. Certainly, the WHO's case has been undermined by scandals. The organization's flustered investigation into the origins of covid-19, as well as damning sexual abuse allegations against staffers during the Congo Ebola outbreak, have led to concerns about the body's ability to stand up to China and an alleged lack of transparency. But for the Biden administration, another issue with WHO funding is closer to home. The United States would at least have to inform U.S. lawmakers in Congress about any increased funding, Gostin said, which could prompt a backlash: "The administration is trying to avoid having to face that politically, particularly when it's coming up to midterm elections and the WHO is not popular in the country." | 
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