The U.S. Government and the World Health Organization

The U.S. Government and the World Health Organization

Key Facts

The World Health Organization (WHO), founded in 1948, is a specialized agency of the United Nations with a broad mandate to act as a coordinating authority on international health issues. It is currently helping coordinate a worldwide response to COVID-19, which it declared to be public health emergency of international concern (PHEIC) on January 30, and a global pandemic on March 11, 2020.
The U.S. government (U.S.) has long been actively engaged with WHO, providing financial and technical support as well as participating in its governance structure.
While the U.S. had been the largest funder of the WHO, providing between $400 million to $500 million each year, the Trump administration suspended financial support to the organization last year, pending a review of its COVID-19 response, and initiated a process to formally withdraw U.S. membership. President-elect Joe Biden has said that he would reverse this decision and restore WHO funding, once he takes office.
The WHO faces challenges going forward, including a broad mandate with limited, inflexible funding, and bureaucratic complexity. While it has instituted changes to address prior weaknesses in its health emergencies program, many governments are calling for further changes to allow it to better respond to future pandemics.

What is the World Health Organization (WHO)?
The WHO, founded in 1948, is a specialized agency of the United Nations (see Table 1). As outlined in its constitution, WHO has a broad mandate to “act as the directing and coordinating authority on international health work” within the United Nations system. It is made of 194 member states.

Founded:
1948

Headquarters:  
Geneva, Switzerland

Regional Offices (Semi-Autonomous):
AFRO (Africa)EMRO (Eastern Mediterranean)EURO (Europe)PAHO (The Americas)SEARO (Southeast Asia)WPRO (Western Pacific)

# of Member States:
194

Budget:
$4.84 billion over two years (2020-2021)**Actual revenue and expenditures may differ from budgeted amount.

Mission and Priorities
Its overarching mission is “attainment by all peoples of the highest possible level of health.” It supports its mission through activities such as:

providing technical assistance to countries,
setting international health standards and providing guidance on important health issues,
coordinating and supporting international responses to health emergencies such as disease outbreaks, and
promoting and advocating for better global health.

The organization also serves as a convener and host for international meetings and discussions on health issues. While WHO is generally not a direct funder of health services and programs in countries, it does provide supplies and other support during emergencies and carries out programs funded by donors.
WHO’s overarching objective for its work during the 2019-2023 period has been “ensuring healthy lives and promoting well-being for all at all ages.” In pursuit of this objective, it has been focusing on three strategic priorities (the “triple-billion targets”):

helping 1 billion more people benefit from universal health coverage;
ensuring 1 billion more people are better protected against health emergencies; and
helping 1 billion more people enjoy better health and well-being.

Achievements
The agency has played a key role in a number of global health achievements, such as the Alma-Ata Declaration on primary health care (1978), the eradication of smallpox (formally recognized in 1980), the Framework Convention on Tobacco Control (adopted in 2003), and the 2005 revision of the International Health Regulations (IHR), an international agreement that outlines roles and responsibilities in preparing for and responding to international health emergencies.
Organization
WHO has a headquarters office located in Geneva, Switzerland, six semi-autonomous regional offices that oversee activities in each region, and a network of country offices and representatives around the world. It is led by a Director-General (“DG”), currently Dr. Tedros Adhanom Ghebreyesus, who was elected to a five-year term beginning July 2017 and has indicated that strengthening WHO as an organization, including addressing management and personnel matters, will be a major focus of his term.
World Health Assembly
The World Health Assembly (WHA), comprised of representatives from WHO’s 194 member states, is the supreme decision-making body for the agency and is convened annually. It is responsible for selecting the DG, setting priorities, and approving WHO’s budget and activities. Every six years the WHA negotiates and approves a work plan for WHO (the most recent plan, known as the general programme of work, covers 2019-2023), and every two years it approves a biennial budget for the work plan (the current budget is for 2020-2021). The annual WHA meeting in May also serves as a key forum for nations to debate important health policy issues.
Executive Board
WHO’s Executive Board, comprised of 34 members technically qualified in the field of health, facilitates the implementation of the agency’s work plan and provides proposals and recommendations to the Director-General and the WHA. The 34 members are drawn from six regions:

7 represent Africa,
6 represent the Americas,
5 represent the Eastern Mediterranean,
8 represent Europe,
3 represent South-East Asia, and
5 represent the Western Pacific.

Member states within each region designate members to serve on the Executive Board on a rotating basis. The U.S. is currently a member of the Executive Board, as one of the representatives from the Americas.
Budget
WHO relies on contributions from member states and private organizations for funding to implement its budget and work plan. The biennial WHO budget for 2020-2021 has been set at $4.84 billion. However, actual revenue and expenditures over that period may deviate from the budgeted amount, such as when additional expenditures occur in response to health emergencies.
Revenue
WHO has two primary sources of revenue:

assessed contributions (set amounts expected to be paid by member-state governments, scaled by income and population) and
voluntary contributions (other funds provided by member states, plus contributions from private organizations and individuals).

Most assessed contributions are considered “core” funding, meaning they are flexible funds that are often used to cover general expenses and program activities. Voluntary contributions, on the other hand, are often “specified” funds, meaning they are earmarked by donors for certain activities.
Several decades ago, the majority of WHO’s revenue came from assessed contributions, but over time, voluntary contributions have come to comprise the greater share of WHO’s budget. For 2018-2019, assessed contributions totaled $956.9 million (17% of revenue), while voluntary contributions totaled $4.49 billion (80%). “Other revenue” totaled $178.1 million (3% of revenue). See Figure 1.
Figure 1: World Health Organization (WHO) Revenue by Type, 2018-2019
Activities
WHO’s activities, as identified in its programme budget for 2020-2021, are organized and funded around its three strategic priorities and a few other key programs, such as polio eradication (see Table 2).

Category
 
2020-2021 Budget*in $ millions
 

One billion more people benefiting from universal health coverage
1,358.8

One billion more people better protected from health emergencies
888.8

One billion more people enjoying better health and well-being
431.1

More effective and efficient WHO better supporting countries
1,090.0

Polio eradication
863.0

Special programs
208.7

TOTAL
4,840.4

NOTES: *These are budgeted amounts. Actual revenue and expenditures over the two-year period may differ from these amounts. Sum of category budgets may not equal total due to rounding.

Each of these strategic priority categories is made up of sub-groups of activities, For instance, under the universal health coverage goal, WHO activities include “improved access to quality essential health services,” “improved access to essential medicines, vaccines, diagnostics, and devices for primary health care,” and other activities. Under health emergencies, WHO activities include “health emergencies rapidly detected and responded to” and “countries prepared for health emergencies.”
Challenges
WHO faces a number of institutional challenges, including:

a scope of responsibility that has grown over time while its budget has remained flat or been reduced;
a budget that has become less flexible with much greater reliance on voluntary contributions often earmarked for specific activities;
a cumbersome, decentralized, and bureaucratic governance structure; and
a dual mandate of being both a technical agency with health expertise and a political body where states debate and negotiate on sometimes divisive health issues.

These and other challenges were particularly evident after the perceived failures of the agency during the response to Ebola in West Africa in 2014-2015, and many called for significant reform of the agency as a result. The agency adopted a number of reforms after 2015 such as reorganizing its approach to outbreaks and health emergencies by creating a Health Emergencies Programme, and standing up new special emergency financing mechanisms such as the Contingency Fund for Emergencies. The reforms seem to have improved WHO capabilities since 2014, for example with an improved response to recent Ebola outbreaks in Democratic Republic of Congo. The organization faces an even greater challenge now, in coordinating a global response to COVID-19, declared to be a PHEIC on January 30, 2020, and a global pandemic on March 11, 2020.
U.S. Engagement with WHO
The U.S. government has long engaged with WHO in many ways including through financial support, participation in governance, and other activities (see below). During the course of the COVID-19 pandemic, however, U.S. engagement has been minimal as the Trump administration moved to distance the U.S. from WHO:

President Trump announced in April that he was putting a hold on U.S. funding to WHO “while its mismanagement of the coronavirus pandemic is investigated” and notified WHO in May that if the organization did “not commit to making substantive improvements within the next 30 days” he would make his “temporary freeze” of U.S. funding “permanent” and “reconsider [U.S.] membership in the organization.”
In July, the U.S. government officially notified the United Nations Secretary General of the decision to withdraw the U.S. from membership in WHO, which according to U.S. law would take effect one year later on July 6, 2021.
President-elect Biden has said that he will “immediately restore” the U.S. relationship with WHO, including funding, and reverse the decision to withdraw U.S. membership. It is likely that the U.S. will become actively involved in efforts to reform WHO procedures for preparing for and responding to future pandemics.

Financial Support
One of the main ways in which the U.S. government supports WHO is through assessed and voluntary contributions; the U.S. had been the single largest contributor to WHO. In 2019, including assessed and voluntary contributions, the U.S. provided WHO an estimated $419 million.
For many years, the assessed contribution for the U.S. has been set at 22% of all member state assessed contributions, the maximum allowed rate. Between FY 2010 and FY 2019, the U.S. assessed contribution has been fairly stable, fluctuating between $107 million and $119 million (see Figure 2).
Figure 2: U.S. Contributions to the World Health Organization (WHO), by Type of Contribution, FY 2010-FY 2019

Voluntary contributions for specific projects or activities, on the other hand, have varied to reflect changing U.S. priorities and support during international crises. Over the last ten years, U.S. voluntary contributions have ranged from a low of $102 million in 2014 to a high of $401 million in 2017. Higher amounts of voluntary contributions can be reflective of increased U.S. support for specific WHO activities such as health emergency response. U.S. voluntary contributions also support a range of other WHO activities such as polio eradication; maternal, newborn, and child health programs; food safety; and regulatory oversight of medicines.
WHO reports that U.S. assessed and voluntary contributions together represented approximately 16% of WHO’s total revenue in the 2018-2019 biennium and approximately 20% of WHO’s programme budget in 2018-2019.
Governance Activities
The U.S. participates in WHO governance, including as a current Executive Board member. The U.S. has historically been an active and engaged member of the World Health Assembly, sending a large delegation usually led by a representative from the Department of Health and Human Services with multiple other U.S. agencies and departments also participating.
Technical Support
The U.S. provides technical support to WHO through a variety of activities and partnerships. This includes U.S. government experts and resources supporting WHO research and reference laboratory work, and participation of U.S. experts on advisory panels and advisory groups convened by WHO. In addition, a number of U.S. government representatives have at times been seconded or have served as liaisons at WHO headquarters and WHO regional offices, working day-to-day with staff on technical efforts. However, the Trump administration said it would scale down its engagement with WHO and recall some detailees, and determine participation in WHO technical and other meetings on a case by case basis.
Partnering Activities
The U.S. has also worked in partnership with WHO before and during responses to outbreaks and other international health emergencies. For example, U.S. government experts have often participated in international teams that WHO organizes to investigate and respond to outbreaks around the world. For example, the U.S. worked with WHO and the broader multilateral response to the Ebola epidemic in West Africa that began in 2014, and U.S. scientists were part of the WHO delegation that visited China in February 2020 to examine its response to COVID-19.
Key Issues for the U.S.
While the U.S. government had long supported WHO and been its largest donor, the Trump administration has reversed course, criticizing the organization, withdrawing financial support, and starting the process to end U.S. membership. The incoming Biden administration has vowed to restore support and continue membership but will be faced with challenges in working to strengthen WHO. These will include questions about how best to improve the organization’s effectiveness, particularly regarding its role in preparing for and responding to pandemics, whether the organization should have more authority over country responses during emergencies, the scope of the WHO mission, and the balance between U.S. support for WHO’s core functions and more specialized programming.

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