How the World Health Organisation works — or doesn’t

Founded in 1948, the UN health agency has been dragged into a geopolitical storm over its handling of the COVID-19 pandemic.

Australia and other western countries have not followed Donald Trump’s lead on defunding the World Health Organisation (WHO), but there’s been plenty of anti-WHO noises from local politicians.

So how did the WHO come to be perceived like this? And is the criticism warranted?

Who funds WHO?

To understand the WHO’s diplomatic balancing act and competing priorities, it’s useful to start with the money. The WHO’s total 2019 budget is US$5.6 billion (about A$8.8 billion). To put that into context the Australian Health Department budget for 2019-20 was A$104 billion.

The WHO’s funding comes from a mix of contributions: obligatory “assessed contributions” reflecting a country’s population and gross domestic product (GDP), and voluntary contributions from states and the private sector.

The United States and some other western countries froze their assessed contributions during the height of the Cold War — they now only raise about 20% of the WHO’s funding, barely enough to cover administrative costs.

That means the bulk of WHO funding comes from voluntary donations, which are largely conditional, said Dr David Legge, an emeritus professor in public health at La Trobe University, who works with civil society organisation WHO Watch.

“Every second year, the WHO adopts a biennial budget based on the priorities of the World Health Assembly [the annual forum of all 194 members states],” Legge said.

“The director-general then goes out with cap in hand to find out which donors will fund this. In effect, all of the programmatic expenditure, including its expenditure on emergency preparedness, depends upon donors.”

Because this funding comes with strings attached, the organisation’s priorities can get skewed. For example, the WHO puts considerable resources into polio eradication because of conditional funding from the Gates Foundation. 

The diplomatic quagmire

The United States provides the largest assessed and voluntary contributions, far outstripping China. So why does it look like the WHO is kowtowing to China?

The answer is complicated — the WHO operates in tricky diplomatic terrain, where it must work hard not to alienate powerful countries too much. That means walking a tightrope on issues like Taiwan.

“It’s very sensitive — if you’ve got to say something positive about Taiwan, you have to accept that you’ll get bashed up by Beijing,” Legge said. 

The decision to recognise Taiwan is voted on by member states in the World Health Assembly each year and, most years, China uses its substantial influence to exclude it. The WHO secretariat has no input here, but rather, has the assembly’s decision foisted on it. That means some of the anger from Australian MPs at the WHO is misplaced.

For similar reasons, the WHO has been careful not to single out individual countries for criticism. As Devi Sridhar, a public health professor at the University of Edinburgh told the BBC, criticising China would’ve given the WHO “five minutes of fame” but it could’ve also hampered global efforts to fight the virus, since it needs China to share data and work with the rest of the world. 

Still, some of the WHO’s steps, from calling for wet markets to be reopened, to the darkly absurd episode of assistant director-general Bruce Aylward clumsily avoiding questions on Taiwan in an interview that went viral, appear overly deferential.

Other issues, like perceived slowness to declare a pandemic, and lack of clarity over border closures likely have a more innocent explanation — the rapid and unpredictable spread of COVID-19.

“You have to cut the guy [director-general Tedros Adhanom Ghebreyesus] some slack,” Legge said.

“This is a totally new disease, it’s much worse than other coronaviruses we’ve had, like SARS and MERS, but at the time, it wasn’t such a crazy thing to assume it would behave like them.”

The WHO’s response could also be influenced by past experiences — in 2009, then-director-general Margaret Chan was criticised for jumping the gun and labelling H1N1 a pandemic too soon. Unlike COVID-19, it largely petered out. 

What will the impacts be?

Regardless of what the WHO has done right or wrong, Trump’s decision to pull funding will be devastating for global health.

Trump’s decision has been slammed by health experts around the globe, with Richard Horton, editor-in-chief of journal The Lancet, calling it “a crime against humanity”.

Without American money, the WHO would have to dramatically scale back its program work. That could include measures to combat rare tropical diseases, or making life-saving medicines available and affordable across the developing world. It could gut the WHO’s emergency preparedness budget — money needed to protect poorer countries in the kind of emergency we’re having right now.

And in the long-run, it could undercut the Trump administration’s aims, by creating a funding and influence void ripe for Beijing to fill. 

China has experience of dealing with COVID-19, and supplies of medical equipment. It’s also been deepening economic ties with African, South American and Pacific countries through its belt and road initiative.

It means that China is well placed to come to the rescue of countries which might otherwise rely on the WHO. Trump might win a symbolic battle with the WHO — a clearly imperfect multilateral organisation — but will it open the way for a fundamental shift in power and influence in a post-COVID-19 world?