According to its constitution, the WHO’s objective is ‘the attainment by all peoples of the highest possible level of health’. Taking advantage of this broad mandate, the organisation has steadily expanded the range of its activities. At the same time, the field of international health has become increasingly crowded, with over 200 players according to one study. These include international organisations such as the World Bank, which branched out into funding health projects in the 1980s, public–private partnerships such as the GAVI Vaccine Alliance, private foundations such as the Bill and Melinda Gates Foundation, and NGOs such as Médecins Sans Frontières. Even at United Nations level, the WHO does not have the field to itself; alongside Unicef and its Children’s and Population Funds, which have taken on some health tasks, the UN also has a dedicated agency on HIV/AIDS; perhaps reflecting a lack of confidence in the WHO’s capacity to tackle the disease, UNAIDS was set up in 1994 on an adjacent but separate site in Geneva. The plethora of global health players, and the WHO’s tendency to spread limited resources across a broad range of tasks, have led to calls for it to focus on areas where it can most clearly offer added value, such as setting international standards and coordinating responses to global health emergencies.
For the 2020-2021 period, the WHO envisages spending US$4.8 billion, compared to US$4.4 billion for 2018-2019. This is a modest amount, given that WHO activities span the entire globe – in the US, there are individual hospitals with larger budgets.
Another problem for the WHO is the nature of its funding. Seventeen per cent comes from ‘assessed contributions’, paid by the member states on the basis of their wealth and population. However, these mandatory payments have not kept pace with the organisation’s needs, and it has become increasingly reliant on donations – from states, international organisations and private foundations. Voluntary contributions are of two types: ‘core’ and ‘specified’. The WHO can spend assessed and core voluntary contributions (3 % of total contributions) flexibly; it therefore has full control over one-fifth of its revenue. The remaining four-fifths comes from specified voluntary contributions, which as their name suggests, are to a greater or lesser extent earmarked by donors for specific purposes. Pre-allocated funding constrains the WHO’s capacity to set its own priorities and allocate resources where they are needed most. On top of this, dealing with funding that comes not in large chunks but in many small, separately managed grants – over 3 000 of them in 2018 – is an administrative headache. Given that the US provides around one-sixth of the budget, if it follows through on its April 2020 threat to suspend contributions, the WHO’s financial position will become even more precarious.