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. The organization has played an important role in helping countries mount a response to the COVID-19 pandemic.
• 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.
• The U.S. has historically been one of the largest funders of WHO, providing between $200 million and $600 million annually over the last decade. In 2020, the Trump administration suspended financial support and initiated a process to withdraw the U.S. from membership in the organization, but President Biden reversed that decision upon taking office in January 2021 and restored U.S. funding to WHO.
• The WHO faces many challenges going forward, including having a broad mandate but limited, inflexible funding, as well as a complex bureaucratic structure. While the organization has instituted changes to address some of these issues, many governments, including the U.S., are calling for further reforms to allow WHO to better respond to future epidemics and pandemics as well as other global health issues, and are also exploring the possibility of increasing core funding to the organization.

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 has 194 member states.

Table 1: WHO Basics
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:	$6.127 billion over two years (2022-2023)* *Approved programme budget; actual revenue and expenditures may differ from budgeted amount.

Mission and Priorities

WHO’s overarching mission is “attainment by all peoples of the highest possible level of health.”¹ 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.²

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”):³

• 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 first appointed in 2017 and is expected to be re-appointed to a second five-year term in May 2022. In addition to coordinating the ongoing COVID-19 response, Dr. Tedros has indicated that strengthening WHO in terms of its financing, staffing, and operations is a major focus for his tenure, and in light of the challenges from COVID-19, has proposed a more robust role for WHO in preparing for and responding to future pandemics.⁴

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 Director-General, 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),⁵ and every two years it approves a biennial budget for the work plan (the current budget is for 2022-2023). The annual WHA meeting in May also serves as a key forum for nations to debate and make decisions about health policy and WHO organizational 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.⁶ The 34 members are drawn from six regions:⁷

• 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 not a current member of the Executive Board but is expected to begin a new three-year term in May 2022.⁸

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 2022-2023 has been set at $6.12 billion (a 5% increase from the $5.84 billion budgeted for the previous biennium, 2020-2021⁹). WHO’s actual revenue and expenditures can deviate from the budgeted amount, such as when additional resources are received and directed in response to health emergencies, including COVID-19.

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).¹⁰

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.¹¹ For the most recent budget period (2020-2021), assessed contributions totaled $956.9 million (13% of revenue), voluntary contributions totaled $6.57 billion (87%), and “other revenue” totaled $51.8 million (<1%).^12,13 See Figure 1.

A working group of WHO member states has been considering different proposals for how contributors might provide WHO with additional, and more predictable, funding and reduce its reliance on specified voluntary contributions.¹⁴ One proposal to emerge from the working group is to increase the size of member states’ assessed contributions for “core” funding over time, the growth of which could be linked to WHO meeting certain organizational reform benchmarks. Many key governments, including the U.S., have expressed support for this proposal.¹⁵ Member states have yet to officially approve a revised revenue approach, but working group recommendations will be discussed at upcoming WHO governance meetings including the World Health Assembly.¹⁶

Activities

WHO’s activities, as identified in its programme budget for 2022-2023, are organized and funded around several core budget segments and key programs, such as polio eradication and emergency operations (see Table 2).¹⁷

“Base programmes” refers to the core support provided for WHO headquarters and regional operations and efforts such as improving access to quality essential health services, essential medicines, vaccines, diagnostics, and devices for primary health care. “Emergency operations” includes WHO efforts to help countries prepare for and respond to health emergencies, including COVID-19. “Special programmes” includes a number of WHO-led initiatives such as the Research and Training in Tropical Diseases program and Pandemic Influenza Preparedness (PIP) Framework activities.

Challenges

WHO faces a number of institutional challenges, including:

• a scope of responsibility that has expanded over time with little growth in its core budget;
• an inflexible budget dominated in recent years by less predictable 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 during and after perceived failures of the agency in the response to the Ebola epidemic in West Africa (2014-2015), after which the agency adopted a number of reforms including reorganizing its approach health emergencies¹⁹ and standing up new special emergency financing mechanisms such as the Contingency Fund for Emergencies.²⁰ Since 2020, WHO has faced one of its greatest challenges to date: coordinating a global response to the COVID-19 pandemic. Many member states, including the U.S., have criticized WHO for its handling of the COVID-19 response and called for further reforms to the organization even as they have recognized the continuing importance of WHO in the global health system.

U.S. Engagement with WHO

The U.S. government has long been engaged with WHO in many different ways including through financial support, participation in governance and diplomacy, and joint activities (see below). In 2020, after the onset of the COVID-19 pandemic, the Trump administration suspended financial support and initiated a process to withdraw the U.S. from membership in the organization, marking a turning point in the U.S. relationship with WHO.²¹ President Biden reversed that decision upon taking office in January 2021 and restored U.S. funding to WHO.²²

Financial Support

One of the main ways in which the U.S. government supports WHO is through assessed and voluntary contributions. The U.S. has historically been the single largest contributor to WHO, though in the 2020-2021 period (when President Trump withheld some U.S. funding during the COVID-19 pandemic) it was the second largest as other donors, notably Germany, increased their contributions (see more below). In 2021, under restored funding from the Biden administration, the U.S. provided WHO an estimated $581 million in combined assessed and voluntary contributions.

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.²³ Between FY 2014 and FY 2022, the U.S. assessed contribution has been fairly stable, fluctuating between $110 million and $123 million (in FY 2019 and FY 2020 the U.S. actually paid less than its assessed amount, and in FY 2021 it paid more than that amount due to payments made toward outstanding arrears). See Figure 2.

Voluntary contributions for specific projects or activities, on the other hand, have varied to reflect changing U.S. priorities and/or support during international crises. Over the past decade, U.S. voluntary contributions have ranged from a low of $102 million in FY 2014 to a high of $402 million in FY 2017. Higher amounts of voluntary contributions can be reflective of increased U.S. support for specific WHO activities such as 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 9% of WHO’s total revenue in the 2020-2021 biennium, making the U.S. was the second largest donor to WHO during that period.²⁴ The largest donor was Germany, which provided approximately 15% of WHO’s total revenue.²⁵

Governance Activities

The U.S. participates in WHO governance, including frequent service as a member of the Executive Board (and is expected to begin a new three-year term as an Executive Board member in May 2022).²⁶ In addition, 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, U.S. government representatives are often seconded to or have served as liaisons at WHO headquarters and WHO regional offices, working day-to-day with staff on technical efforts.²⁷

Partnering Activities

The U.S. has also worked in partnership with WHO before and during responses to outbreaks and other international health emergencies, including participating 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 assess its response to COVID-19.²⁸

Key Issues for the U.S.

The U.S. has a long history of supporting and working with WHO, and although that relationship was strained during the first year of the COVID-19 pandemic under the Trump administration, relations have normalized once again under the Biden administration. Current U.S. priorities for WHO include instituting funding and governance reforms and assuring greater transparency and accountability from the organization. The U.S. has backed a recommendation to increase the size of member state assessed contributions over time to provide more flexible funding and predictability for the WHO budget, contingent on the organization meeting reform benchmarks. In addition, the U.S. has highlighted the important role played by WHO in addressing global health threats such as epidemics and pandemics and supports strengthening the organization’s pandemic response capacities. The U.S. also supports changes to the International Health Regulations (IHRs), as well as bringing member states together to negotiate a new international legal instrument – a potential “pandemic treaty” – under the auspices of WHO. Even so, there remain many questions about whether and when these proposals may be enacted, how extensive they might be, and about what role the U.S. may play in pushing them forward.