A woman washes her hands from a tank of water bearing a World Health Organization sticker, as a prevention against Ebola

The WHO’s request for more core funding must not be met at the expense of work funded through voluntary contributions.Credit: Junior D. Kannah/AFP/Getty

It’s a little-known fact that the World Health Organization (WHO) lives a hand-to-mouth existence. Governments contribute most of its annual US$6-billion budget, but the WHO is allowed to spend less than 20% of this on its core mission, which is to support public health in the poorest countries and respond to emergencies around the world. Much of the rest consists of voluntary donations earmarked for projects specified by donors, such as eliminating polio or treating HIV/AIDS.

The governments of most of the WHO’s member states are now rightly saying that the agency needs more-predictable funding, as well as the flexibility to decide when and how to spend a greater proportion of its budget — during a pandemic, for example. They should consider how to move ahead with implementing this plan despite the fact that a small number of countries are opposing it.

Since the WHO was founded in 1948, its total spending power has increased nearly sixfold, when adjusted for inflation. But the majority of this money has been provided through voluntary contributions. By contrast, core funding — which comes from assessed contributions, based on a country’s wealth — has decreased in real terms. As a result, the WHO is struggling to achieve a key goal to provide universal health coverage for the most vulnerable populations.

For decades, the WHO’s leadership has tried to persuade its donors to rebalance its funding. Last week, it tried again. At least 120 countries are backing a proposal for half of all funding for the WHO to comprise assessed contributions. This would bring its funding mechanism closer to that of many other United Nations agencies. But eight countries — including, most notably, the United States, but also Brazil, Japan and Poland — are opposing the move.

The United States wants to see how the WHO can increase efficiency before it commits more funding. In 2019 (the last year for which data are available), the United States paid $419 million to the WHO, of which assessed contributions made up $119 million. One way to increase efficiency would be to relieve the agency of the need to devote so many of its resources to the priorities of individual governments.

The US opposition to rebalancing the budget is a surprise, considering President Joe Biden’s full-throated support of the WHO in 2020, when then-president Donald Trump withdrew the United States and its funding from the WHO, saying the agency had become too close to China. At the time, Trump was also considering plans to create a global pandemic-response agency separate from the WHO. Biden reversed the withdrawal on taking office in January 2021, but his administration has restored only about three-quarters of US funding. And earlier this month, reports emerged that the United States is continuing to push for a pandemic-response agency — to be funded by the G20 group of the world’s largest economies and administered by the World Bank in Washington DC. If brought into being, this would compete with the WHO. It would also clash with nascent plans, spearheaded by the European Union and backed by the WHO, to create a pandemic-response pact for countries to sign up to. Despite the change in US leadership, the WHO is still caught up in great-power politics. For the world’s health agency to be politicized at any time is unwise; for it to happen during a pandemic is dangerous.

Countries will need to decide on the proposal to increase the WHO’s assessed contributions by May, when WHO member states meet in Geneva, Switzerland, for the annual World Health Assembly. Realistically, the United States is unlikely to change its position so soon, if at all. But, while it makes up its mind, the many countries that are supporting the proposal should consider how they can press ahead and increase the agency’s core funding. For example, they could increase voluntary contributions that come with no restrictions — known as ‘core voluntary contributions’.

Countries are being asked to increase their assessed contributions from $489 million in 2022–23 to $1.1 billion in 2028–29. When shared between 194 member states, this is not a large sum of money in the context of health care. But, overall, the increase to the WHO’s assessed contributions amounts to a doubling. Such a multiple will be tricky to push through national parliaments. At a time of pressure on government budgets, lawmakers in many countries will question why such an increase is needed.

Funding for the WHO tends to come out of countries’ international-aid budgets, and these budgets are under strain. The pandemic, along with newer crises, such as the collapse of governance in Afghanistan, has meant that there is huge need for international humanitarian assistance, which comes out of aid budgets. At the same time, citizens in some nations are questioning their countries’ aid spending, urging governments to spend more money to tackle the health and economic consequences of the pandemic at home.

One potential solution is for countries’ WHO contributions to come out of their general health spending (in effect, removing it from the aid budget). The logic is that supporting the WHO should not be seen as aid spending, but as spending to protect global public health — including anticipating and preventing or mitigating the next pandemic. Moreover, the WHO’s share of a nation’s health budget will be a much smaller fraction than its share of aid spending, because health budgets tend to be larger. Germany has already made the shift. In 2021, the country spent some €24 billion (US$27 billion) on health care. By contrast, its assessed contribution to the WHO was just $29 million.

One of the biggest risks of the WHO plan is that lawmakers might look to make savings elsewhere, by making cuts to spending on diseases such as HIV/AIDS or malaria, or to childhood immunization campaigns — all of which constitute a significant share of voluntary contributions. It’s crucial that this does not happen.

More funding and a rebalancing of the WHO budget is ultimately not just about money. As important as the cash is, what matters more is the signal increased funding would send that nations value the WHO’s core missions — to be led by scientific evidence and to ensure that people everywhere have the opportunity to live a healthy life.