The U.S. Government and the World Health Organization
- 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, including helping countries mount responses to public health emergencies such as COVID-19.
- 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. The organization has instituted changes to address some of these issues, but 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.
What is the World Health Organization (WHO)?
The WHO, founded in 1948, is a specialized agency of the United Nations. 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.
The agency has played a key role in a number of past 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.
Mission and Priorities
- providing technical assistance to countries;
- setting international health standards and providing guidance on health issues;
- coordinating and supporting international responses to health emergencies such as disease outbreaks; and
- promoting and advocating for better global health.
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”):
- 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.
As part of its work to help countries be better protected against health emergencies and propelled by the issues and challenges faced during the COVID-19 pandemic, WHO is overseeing two sets of international negotiations related to pandemic preparedness and response among member states: a process to review and potentially amend the IHR agreement and the drafting and negotiating of a new agreement, convention, or other international instrument on pandemic prevention, preparedness and response (the “pandemic accord”). Both these negotiations are ongoing and are expected to continue at least through 2024.
WHO has a global reach, with a headquarters office located in Geneva, Switzerland, six semi-autonomous regional offices that oversee activities in each region,1 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 was re-elected to a second five-year term in May 2022. Dr. Tedros has indicated that priorities for his second term include strengthening WHO’s financing, staffing, and operations; building pandemic preparedness and response capacities at WHO and elsewhere; and helping countries re-orient health systems toward primary health care and universal health coverage.
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. 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. Every six years, the WHA negotiates and approves a work plan for WHO, known as the general programme of work. The current plan, covering 2019-2023, has been extended by the WHA through 2025. Every two years the WHA also approves the WHO’s programme budget in support of its work plan; the current programme budget covers the 2022-2023 biennium.2 More information about WHO’s budget provided below.
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. The 34 members are drawn from six regions as follows:
- 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. currently holds a seat on the Executive Board.
WHO supports activities across a number of key areas, organized into several “budget segments,” including “base programmes,” emergency operations, polio eradication, and “special programmes” (see Table 1).3 “Base programmes” refers to the core support provided for WHO headquarters activities, 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 epidemics and other health emergencies such as COVID-19, mpox, and natural disasters. “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.
WHO has a programme budget set in advance by member states, which is meant to outline planned activities to meet its work plan over a two-year period (biennium) and describes the “resource levels required to deliver that work.” The programme budget for 2022-2023 was initially set at $6.12 billion, but in 2022, member states agreed to revise the programme budget upward to $6.72 billion to allow for additional spending related to COVID-19 response and other issues. The revised amount represents a 15% increase over WHO’s prior 2020-2021 programme budget of $5.84 billion. The programme budget for the next biennium (2024-2025), approved by member states at the 2023 WHA, is set at $6.86 billion.
The programme budget represents a plan for the organization’s anticipated resources, but actual resources may deviate from the initial budgeted amounts over course of the biennium due to changing or unexpected circumstances, such as additional resources (revenue) provided to WHO for emergency responses or lower levels of support than expected. For example, in the current biennium WHO expects (as of April 2023) that programme resources will total more than $10 billion, due to additional funding being received or directed in support of emergency operations, including COVID-19 response, and polio eradication activities. See Table 1 for more details.
|Table 1: WHO 2022-2023 Biennial Programme Budget*
(in $ millions)
|Budget Segment||Planned Programme Budget
(as revised in May 2022)
|Current Programme Budget*
(as of April 2023)
|Emergency operations and appeals (including COVID-19 response)||1,000.0||3,994.8|
|NOTES: *Current programme budget includes projected amounts and remaining shortfalls. Actual resources (revenue and expenditures) at the end of the biennium may differ from these amounts due to additional voluntary contributions from donors (particularly in support of emergency operations) or lower donor contributions than expected. Sum of budget segment amounts may not equal total due to rounding. Data as of April 2023.
SOURCES: WHO. Financing of 2022-23 Biennium: Programme Budget Until Q2-2023 (April). Accessed May 16, 2023. http://open.who.int/2022-23/budget-and-financing/summary Also see WHO. Programme Budget 2022-2023. https://apps.who.int/iris/bitstream/handle/10665/346071/9789240036109-eng.pdf; WHO. Revision of the Programme budget 2022–2023. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_R5-en.pdf
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).
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. For example, in the current budget period (2022-2023), as of April 2023, assessed contributions totaled $956.9 million (12.1% of total revenue to date), voluntary contributions totaled $6.92 billion (87.5% of total revenue to date), and “other revenue” totaled $28.1 million (0.4%).4 See Figure 1.
Reliance on voluntary, relatively inflexible funding has, in WHO’s view, hampered its operations and effectiveness. In 2022, member states, including the U.S., agreed in principle to move toward more predictable, flexible funding for WHO and to reduce the role of specified voluntary contributions. Recommended funding changes include: increasing assessed contributions starting in the 2024-2025 biennium and instituting a goal to have 50% of WHO’s program budget be financed through assessed contributions by 2030, which could be linked to WHO meeting certain organizational benchmarks. Member states are also exploring the option of using a “replenishment” mechanism for WHO, which could allow for more stable and predictable funding by attracting new donors and allowing multi-year donor commitments. At the May 2023 WHA, member states approved a 20% increase in assessed contributions for the next (2024-2025) biennium as a first step in reshaping WHO’s budget; further changes or increases in funding for WHO will be voted on in future WHA meetings.
WHO faces a number of institutional challenges, including:
- a scope of responsibility that has expanded over time with little growth in core, non-emergency funding;
- 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), and in the criticisms directed at WHO as it tried to help coordinate a global response to the COVID-19 pandemic. Even as many member states continue to support WHO and recognize its importance for global health, many are also calling for reforms to the organization that would help address its weaknesses. WHO itself supports reforms in several areas to help address some of these ongoing concerns.
U.S. Engagement with WHO
The U.S. government has long been engaged with WHO in multiple 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.5 Under the Biden administration, U.S. relations with the organization were re-established in January 2021, and U.S. funding to WHO was restored.6
One of the main ways in which the U.S. government supports WHO is through its assessed and voluntary contributions. The U.S. has historically been the single largest contributor to WHO. In the 2020-2021 period though (when the Trump administration withheld some U.S. funding during the COVID-19 pandemic), it was the third largest as other donors, notably Germany and the Bill and Melinda Gates Foundation, increased their contributions in response to COVID-19; in 2021, under restored funding from the Biden administration, the U.S. provided WHO an estimated $583 million in combined assessed and voluntary contributions. For the 2022-23 period, the U.S. is once again the largest contributor to WHO (see more below).
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. Between FY 2014 and FY 2023, 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; mental health services for victims of torture and trauma; health coordination in COVID-19 response; and other infectious diseases.
WHO reports that U.S. assessed and voluntary contributions together represented approximately 15% of WHO’s total revenue in the 2022-2023 biennium, making the U.S. was the largest donor to WHO during that period.
The U.S. is an active participant in WHO governance, including through the Executive Board and the World Health Assembly (WHA). The U.S. currently holds a seat on the WHO Executive Board through 2025.7 The U.S. has historically been an active and engaged member of the WHA, sending a large delegation each year that has typically been led by a representative from the Department of Health and Human Services, with multiple other U.S. agencies and departments also participating.
The U.S. provides technical support to WHO through a variety of activities and partnerships. This includes U.S. government experts and resources supporting research and reference laboratory work via WHO collaborating centres8 and participation of U.S. experts on advisory panels and advisory groups convened by WHO. The U.S. contributions to WHO collaborating centres include technical areas such as cancer, occupational health, nutrition, chronic diseases, and improving health technologies.9 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.10
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. To help further develop areas of partnership and coordination, the Biden administration has instituted semi-regular “strategic dialogue” meetings to create a regular forum for discussions between key U.S. and WHO officials.
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 supported increasing assessed contributions over time to provide more flexible funding and predictability for the WHO budget, contingent on the organization meeting reform benchmarks. The U.S. often highlights 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; this includes U.S. recommending a set of revisions to the International Health Regulations (IHRs), and support for the process to create a new international legal instrument – a potential “pandemic accord” – under the auspices of WHO. Even so, there remain many questions about whether and when many of these proposals will be enacted, how extensive they might be, and what role the U.S. may play in helping adopt them.
These include: AFRO (Africa), EMRO (Eastern Mediterranean), EURO (Europe), PAHO (The Americas), SEARO (Southeast Asia), and WPRO (Western Pacific).
WHO. Programme Budget 2022-2023. https://apps.who.int/iris/bitstream/handle/10665/346071/9789240036109-eng.pdf; WHO. Revision of the Programme budget 2022–2023. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_R5-en.pdf. Also see WHO. Financing of 2022-23 Biennium: Programme Budget Until Q2-2023 (April). Accessed May 16, 2023. http://open.who.int/2022-23/budget-and-financing/summary.
WHO. Financing of 2022-23 Biennium. Webpage, accessed May 16, 2023. http://open.who.int/2022-23/budget-and-financing/summary. Also see WHO. Programme Budget 2022-2023. https://apps.who.int/iris/bitstream/handle/10665/346071/9789240036109-eng.pdf; WHO. Revision of the Programme budget 2022–2023. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_R5-en.pdf.
WHO. Contributors 2022-2023. http://open.who.int/2022-23/contributors/contributor. Data through April 2023. Accessed May 17, 2023. “Other revenue” includes contributions to the PIP (pandemic influenza preparedness) partnership.
Trump Administration/White House. “President Donald J. Trump Is Demanding Accountability From the World Health Organization.” Fact Sheet. April 15, 2020; Trump Administration/White House. Letter to Dr. Tedros Adhanom Ghebreyesus, WHO Director-General from President Trump. May 18, 2020.; Trump Administration/White House. “Remarks by President Trump on Actions Against China.” Remarks by President Trump on May 29, 2020. May 30, 2020; Trump Administration/U.S. Department of State. “Update on U.S. Withdrawal from the World Health Organization.” Press Statement by Morgan Ortagus, Department Spokesperson. Sept. 3, 2020. https://2017-2021.state.gov/update-on-u-s-withdrawal-from-the-world-health-organization/index.html.
White House, “Letter to His Excellency António Guterres,” correspondence from President Biden, Jan. 20, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/01/20/letter-his-excellency-antonio-guterres/; Associated Press. ‘Biden’s US revives support for WHO, reversing Trump retreat’. January 2021. https://apnews.com/article/us-who-support-006ed181e016afa55d4cea30af236227; HHS, “Dr. Anthony S. Fauci Remarks at the World Health Organization Executive Board Meeting,” Jan. 21, 2021, https://www.hhs.gov/about/news/2021/01/21/dr-anthony-s-fauci-remarks-world-health-organization-executive-board-meeting.html.
WHO. “Composition of the Board: Members of the Executive Board and Term of Office.” Webpage. https://apps.who.int/gb/gov/en/composition-of-the-board_en.html; White House. Fact Sheet: The Biden Administration’s Commitment to Global Health. February 2022. https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/02/fact-sheet-the-biden-administrations-commitment-to-global-health/.
WHO collaborating centres are “institutions such as research institutes, parts of universities or academies, which are designated by the Director-General to carry out activities in support of” WHO programs; see: WHO. “Collaborating centres” https://www.who.int/about/collaboration/collaborating-centres .
For example, the U.S. CDC activities support centres such as the WHO Collaborating Centre for International Monitoring of Bacterial Resistance to Antimicrobial Agents (https://apps.who.int/whocc/Detail.aspx?mDXUc+J7YSsPRDN4ElrZNw==), the WHO Collaborating Centre for Injury Control (https://apps.who.int/whocc/Detail.aspx?XidWfagjyJM57zUuxiHDVg==). (https://apps.who.int/whocc/Detail.aspx?xIVob4SPT2jc+ZYjM7fcSQ==) and the WHO Centre for Surveillance, Epidemiology and Control of Influenza (https://www.cdc.gov/flu/weekly/who-collaboration.htm).
CDC. CDC Global Health Partnerships. https://www.cdc.gov/globalhealth/partnerships.htm.