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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.
  • 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. is currently the largest contributor to WHO.
  • The WHO faces a number of challenges including a broad mandate with limited, inflexible funding, bureaucratic complexity, and a track record of poor responses to recent health emergencies; reforms have been initiated to address some of these challenges.

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.

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: $4.422 billion over two years (2018-2019)*

*Actual revenue and expenditures may differ from budgeted amount.

Mission

Its 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. For the most part, WHO is not a direct funder of health services and programs in countries.

WHO’s overarching objective for its work during the 2019-2023 period is “ensuring healthy lives and promoting well-being for all at all ages.” In pursuit of this objective, it will focus on three strategic priorities (the “triple-billion target”)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 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.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 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),3 and every two years it approves a biennial budget for the work plan (the current budget is for 2018-2019).  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.5 The 34 members are drawn from six regions:6

  • 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, representing the Americas.

Budget

WHO relies on contributions from member states and private organizations for funding to implement its budget and work plan. The draft biennial WHO budget for 2018-2019 has been set at $4.422 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).7

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 the donor for certain activities.

Figure 1: World Health Organization Revenue by Type, 2016-2017

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.8 For 2016-2017, assessed contributions totaled $927 million (18% of revenue), while voluntary contributions totaled $4.116 billion (80%).9 “Other revenue” totaled $96 million (less than 2% of revenue).10 See Figure 1.

Activities

WHO’s activities, as identified in WHO’s biennial budget 2018-2019,11 include the following (see Table 212):

  • communicable diseases;
  • corporate services and enabling functions;
  • health emergencies programme;
  • health systems;
  • promoting health through the life course;
  • non-communicable diseases; and
  • other areas, including polio eradication, tropical disease research, and research in human reproduction.

Each of these categories is made up of “programme areas.” For instance, communicable diseases has six programme areas, including HIV/AIDS and tuberculosis.

 

Table 2: WHO Biennial Budget (2018-2019), by Category
Category Budget*
(2018-19)
in $ millions
Communicable diseases 805
Corporate services and enabling functions 716
Health emergencies programme 554
Health systems 590
Non-communicable diseases 351
Promoting health through the life course 384
Other areas:
  -Polio eradication 903
  -Tropical disease research 50
  -Research in human reproduction 68
TOTAL 4,422
*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.

Challenges

WHO faces a number of institutional challenges, including:13

  • 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 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.14 The agency has adopted a number of reforms since 2015 such as reorganizing its approach to outbreaks and health emergencies by creating a Health Emergencies Programme,15 and standing up new special emergency financing mechanisms.16 The reforms appear to have improved WHO capabilities, as demonstrated by an improved response to recent Ebola outbreaks in Democratic Republic of Congo17

U.S. Engagement with WHO

The U.S. government engages with WHO in many ways, as follows:

Financial Support

One of the main ways in which the U.S. government supports WHO is through assessed and voluntary contributions; the U.S. is the single largest contributor to WHO. 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.18 Between FY 2010 and FY 2017, the U.S. assessed contribution has been fairly stable, fluctuating between $107 million and $114 million (see Figure 2).

Figure 2: U.S. Contributions to the World Health Organization, by Type of Contribution, FY 2010-FY 2017

Figure 2: U.S. Contributions to the World Health Organization, by Type of Contribution, FY 2010-FY 2017

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 eight years, U.S. voluntary contributions have ranged from a low of $102 million in 2014 to a high of $401 million in 2017, the higher amount reflective of increased U.S. support for WHO’s responses to health emergencies. 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.

U.S. assessed and voluntary contributions together represented approximately 17% of WHO’s total revenue in the 2016-2017 biennium.19

Governance Activities

The U.S. participates in WHO governance, including as a current Executive Board member. The U.S. is also 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 are seconded or serve as liaisons at WHO headquarters and WHO regional offices, working day-to-day with staff on technical efforts.20

Partnering Activities

The U.S. also works in partnership with WHO before and during responses to outbreaks and other international health emergencies. For example, U.S. government experts often participate 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.

Key Issues for the U.S.

The U.S. government has long supported WHO and continues to be its largest donor at a moment when WHO is undergoing major reforms. Going forward, there are several key questions regarding U.S. engagement with the WHO, including:

  • the extent to which the U.S. will continue its financial and other support of WHO and what role it will play in WHO’s governance and helping it enact needed reforms;
  • the progress made by WHO under the leadership of its new Director-General in improving the effectiveness of the organization and addressing its challenges; and
  • the quality of technical and governance partnerships between the U.S. and WHO, especially in the event of a new public health emergency or outbreak in the future.
Endnotes
  1. Constitution of the World Health Organization, Chapter 1, Article 1. http://www.who.int/governance/eb/who_constitution_en.pdf.

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  2. Clift C. The Role of the World Health Organization in the International System. Chatham House Centre for Global Health Security.  http://www.chathamhouse.org/publications/papers/view/189351.

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  3. World Health Organization. Thirteenth General Programme of Work 2019-2023. https://www.who.int/about/what-we-do/gpw-thirteen-consultation/en/

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  4. World Health Organization. “Director-General Dr Tedros takes the helm of WHO: address to WHO staff [by] Dr Tedros Adhanom Ghebreyesus.” Remarks. July 3, 2017. http://www.who.int/dg/speeches/2017/taking-helm-who/en/.

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  5. World Health Organization website. The Executive Board. http://www.who.int/governance/eb/en/.

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  6. World Health Organization website. Executive Board Members. http://apps.who.int/gb/gov/executive-board-members.html

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  7. World Health Organization. Budget. http://www.who.int/about/finances-accountability/budget/en/.

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  8. World Health Organization. A proposal to increase the assessed contribution. 2016 http://www.who.int/about/finances-accountability/funding/financing-dialogue/assessed-contribution.pdf.

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  9. WHO. Audited Financial Statements for the year ended 31 December 2017. Executive Board Document A71/29, 13 April 2018. http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_29-en.pdf.

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  10. Other includes “re-imbursable procurement” and “other revenue” as reported.

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  11. World Health Organization. WHO 2018-19 Proposed Programme Budget, May 2017. http://www.who.int/about/finances-accountability/budget/PB2018-2019_en_web.pdf?ua=1.

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  12. World Health Organization. WHO 2018-19 Proposed Programme Budget, May 2017. http://www.who.int/about/finances-accountability/budget/PB2018-2019_en_web.pdf?ua=1.

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  13. Clift C. What’s the World Health Organization For? Chatham House. May 2014 https://www.chathamhouse.org/sites/files/chathamhouse/field/field_document/20140521WHOHealthGovernanceClift.pdf.

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  14. Some of the key reports include: WHO’s own commissioned Ebola Interim Assessment Panel http://www.who.int/csr/resources/publications/ebola/ebola-panel-report/en/; Harvard-London School of Hygiene and Tropical Medicine Report http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00946-0/fulltext; National Academy of Medicine, Global Health Risk Framework report https://nam.edu/initiatives/global-health-risk-framework/; and the United Nations High-level Panel on the Global Response to Health Crises report http://www.un.org/News/dh/infocus/HLP/2016-02-05_Final_Report_Global_Response_to_Health_Crises.pdf.

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  15. World Health Organization. Report of the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme. Executive Board Document EB 142/8, 12 January 2018. http://apps.who.int/gb/ebwha/pdf_files/EB142/B142_8-en.pdf.

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  16. World Health Organization. Progress Report on the Implementation of the WHO Health Emergencies Programme, March 2016. http://www.who.int/about/who_reform/emergency-capacities/who-health-emergencies-programme-progress-report-march-2016.pdf.

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  17. Michaud J, Kates J. The Latest Ebola Outbreaks: What Has Changed in the International and U.S. Response Since 2014? 28 Aug 2018 https://www.kff.org/global-health-policy/issue-brief/the-latest-ebola-outbreak-what-has-changed-in-the-international-and-u-s-response-since-2014/.

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  18. World Health Organization. Scale of Assessments for 2016-2017. 26 May 2015 http://www.who.int/about/finances-accountability/funding/A68_R12_en.pdf?ua=1.

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  19. Calculated from: World Health Organization’s Audited Financial Statements for the year ended 31 December 2017. Executive Board Document A71/29, 13 April 2018. http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_29-en.pdf; and WHO reported assessed and voluntary contribution amounts for the United States, http://www.who.int/about/finances-accountability/funding/invoices-2016-17/usa_en.pdf and http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_INF2-en.pdf.

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  20. Centers for Disease Control and Prevention. CDC Global Health Partnerships.  https://www.cdc.gov/globalhealth/partnerships.htm.

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