Why has the withdrawal of the US from the World Health Organisation caused such a shock? President Donald Trump – re-elected with a convincing popular mandate – has simply done what he promised when last in power.
It is unfortunate that the WHO did not use the four intervening years between the two Trump presidencies to prepare for this eventuality. Perhaps they were complacent or they decided against openly making any contingency plans in case that sent the wrong signal.
Either way, dire consequences will flow from the sudden 18 per cent funding squeeze – America’s contribution to the WHO’s finances. Although it will be another year before the US formally leaves the organisation, Mr Trump’s recent executive order includes an immediate pause on “the future transfer of any US government funds, support or resources” including “US government personnel and contractors” working with the WHO.
Because the WHO is halfway through its 2024-25 programming cycle, it will now have to slash its spending priorities as opposed to reorganising in an orderly manner – a process that requires difficult compromises among its 194 member states at the next World Health Assembly in May.
Unsurprisingly, the mood in the WHO is downbeat. Immediate cost-cutting has frozen travel, recruitment and procurement but such measures will not be enough, given that the US-sized billion-dollar gap will not be filled by others.
WHO supporters such as the UK are financially stretched and others, like Germany for example, are shifting rightwards politically. States opposed to Mr Trump’s policy are wary of crossing him by rushing to replace American funding. Others are dissatisfied with the WHO for their own reasons – Argentina is leaving the organisation too.
In short, the most articulate proponents of health multilateralism do not want to pay for it by making up the WHO’s fiscal deficit through increased membership contributions. China’s pushback against higher membership fees at a recent WHO Executive Board meeting in Geneva was noteworthy.
Could private philanthropy rescue the WHO? The Bill and Melinda Gates Foundation contributed a staggering $830 million in the 2022-23 biennium, becoming the WHO’s third-largest contributor. However, this outsized influence – however well-meaning – is culturally disliked by many and distorts WHO priorities.
More problematic is a scenario in which the WHO turns to private companies, especially those providing health products and services. That is encouraged by some countries that are home to multibillion-dollar pharma enterprises. But this raises conflicts of interest and would undermine trust in the organisation’s scientific objectivity. This is particularly worrying in our post-Covid era in which health misinformation is reaching record levels.
Meanwhile, how justified is Mr Trump’s criticism? His principal assertion is that the WHO cannot be trusted because it mishandled the Covid-19 pandemic by being too soft on China, where the disease started. Several other countries agree, claiming that China is reluctant to share information and allow an independent investigation into the virus’s origins.
The WHO privately acknowledges its earlier lack of assertiveness on the issue, but it is a secretariat with no enforcement power over the member states on whose goodwill it depends. That is why it champions a new Pandemic Accord with more teeth. Ironically, this is opposed by the US and its allies who do not want to cede authority to transnational bodies.
This illustrates a fundamental ideological difference among states, between those who favour globalism alongside the supranational centralisation of some functions, and nationalistic opponents guarding their sovereignty. The WHO is caught in the middle, even as it counsels that “no country is safe until all are safe” because diseases do not stop at borders.
However, such wisdom is done no favours by the rhetoric of “global health security”. Militarising language around health co-operation has triggered competition over access to medicines, vaccines and other technologies – including AI. This is because they are seen as ways to create healthy, strong populations and thus advance national interests, rather than health being a moral good in itself.
The WHO cannot square this circle no matter how strongly it preaches humanitarian health values. Its passionate advocacy for health care in Gaza won both friends and foes depending on the side taken in the war. Critics argue that the WHO’s outspokenness politicises and damages its work, something evident in the ritual of divisive Palestine and Taiwan debates at the annual World Health Assembly.
Counter-critics say that the WHO must get more political, relying on its own research into the socio-economic determinants of health. But with the world divided over the merits of individualist and collective methods for health financing, the WHO’s prescriptions to advance its flagship mission on universal health coverage are not to everyone’s taste.
It is in this wider context that Mr Trump has opened the Pandora’s box of WHO financing. He contends that the organisation demands “unfairly onerous payments from the United States”. But what are the facts?
Although the “outcome-based” presentation of WHO budgets is intellectually attractive, as it links funding to results, this makes for complex analysis that can lead to accusations of a lack of financial transparency.
In short, the WHO’s approved $6.8 billion budget for the 2024-25 biennium consists of $4.9 billion base programming for its core mandate, $1 billion for emergency operations, and $0.9 billion for polio eradication and other special programmes. But only 16 per cent of the overall budget is covered by obligatory membership contributions that total $1.1 billion. Of that, several millions may be received late – if at all – from countries in permanent arrears, such as the US itself.
Assessed contributions follow a UN formula to determine a country’s “capacity to pay”. This weighs up its economic strength, population size, income per capita, debt burden and other adjustments. This complex calculation requires contentious data estimates and statistical manipulation. They set the US’s biennial assessment at 22 per cent of the total base programme ($260 million) and China at 15.2 per cent ($175 million). This may be compared, for example, to India’s one per cent ($12 million) and the UAE’s 0.6 per cent ($7 million).
The formula reflects the world that existed in the 1940s and has not kept pace with shifts in the global order because nations that have become richer resist paying more. Neither does the formula serve the WHO well because assessed contributions lag far behind what members ask the organisation to do through numerous mandates. Therefore, 80-90 per cent of WHO work relies on unpredictable voluntary contributions. This effects the consistency and quality of programming, especially when funds are earmarked for favourite projects.
The US, with the world’s biggest gross domestic product, is the most generous voluntary donor, giving $727 million over the 2024-25 period. This is compared to just $28 million from China, the country with the world’s second-largest GDP. In comparison, fifth-ranking India provides $75 million and 28th-ranking UAE gives $65 million. Mr Trump has some justification in claiming that the global health financing burden is unfairly distributed.
Bringing greater financing equity requires the WHO to step up internal efficiency reforms. Although WHO director general Dr Tedros Adhanom Ghebreyesus has made a good start, changing a large bureaucracy is slow. It is also difficult for the WHO to continue justifying locating a third of its 9,400 staff in Geneva. From their place in the world’s second-most expensive city, they may duplicate or be in conflict with the work of staff in six regional and 150 country offices and other hubs. Meanwhile, although the institutional drive for gender parity and geographical diversity is admirable, there are questions of whether merit has been compromised with politically-correct appointments.
The departure of the WHO’s previous regional director for the Western Pacific amid accusations of bullying, and an ongoing corruption investigation relating to the director for the South-East Asia region undermine confidence in WHO governance. And, despite greater transparency around sexual misconduct scandals – as in its Congo operations – cleaning up the WHO through timely justice and accountability remains a work in progress.
But there are bigger strategic issues to grasp. How should the WHO facilitate an international health system that has grown to encompass three other Geneva-based global bodies? Several UN agencies have their own health roles, the World Bank has a massive health portfolio, and there is increased activity from the International Red Cross and Red Crescent, NGOs, foundations and the private sector? Their combined health financing flows total around $65 billion annually. How can the WHO work in this context? Similarly, how should the WHO adjust to greatly increased national capabilities over past decades, with worldwide health expenditures edging towards a staggering $10 trillion annually – about 10 per cent of global aggregate GDP?
The WHO remains globally useful for setting standards, co-ordination and certification, as well as validation purposes. But it is not equally indispensable to all states, as other public health institutions – such as the US, European, Chinese and African centres for disease control – could do the same. In any case, much of the WHO’s specialist work is discharged not by its staff but external experts convened for specific purposes such as advising on pandemic declarations, antimicrobial resistance or optimising tuberculosis treatment, for example.
Can the WHO accept that it could, therefore, reduce the scope of its interventions, even for poorer or ill-governed nations who are unnecessarily aid dependent? It implies reversing the relentless expansion of WHO activities and shrinking organisational size to one that is sustainable. That would be funded through statutory membership contributions set by a new, fairer formula. Perhaps the US may then return to the fold, even if that is not until a new incumbent arrives in the White House.
Mr Trump has precipitated the WHO crisis in a regrettably disruptive manner. But this was coming anyway because business as usual was increasingly untenable. The WHO and its friends must grasp this moment for transformational change or else another crisis will be wasted.
