A Watershed for WHO Finances & Governance?
WHO Investment Rounds: A Replenishment Approach
By Priti Patnaik
Geneva Health Files, May 2023
From responding to health emergencies and developing standards forgenomic surveillance, to regulating trans-fats and monitoring the use of ecigarettes, WHO has a broad mandate and myriad tasks to fulfill.
Yet for all its vast responsibilities, WHO is cash-poor. Its core budget for2022 and 2023 was around US$4.4 billion—smaller than that of many bighospitals. [Note that the base segment of the Programme budget is $4.4billion – without taking into account budget for special programmes,
emergencies and polio eradication.]
Financing the WHO will be a key agenda item at next week’s World Health
Assembly. Here’s why it’s such an important issue.
The challenge for WHO is that only 14% of its funding is fully
flexible, according to a report filed for this year’s WHA. These funds largely
come from membership fees paid by countries known as assessedcontributions, which are flexible in nature and are used to cover theorganization’s core budget. The rest of WHO’s funds are mostly “voluntary”
support from countries and donors that are earmarked for specific programs.
(Some parts of the core voluntary contributions are also flexible to an extent.)
WHO faces another budget hurdle: While it runs on a 2-year budget cycle,
some funding is for periods shorter than 2 years. This introduces lots ofunpredictability in its operations—even in critical areas such as healthemergencies, noncommunicable diseases, mental health, and nutrition toname just a few areas. These chronically underfunded areas are known inWHO parlance as “persisting pockets of poverty.”Image Credit: Photo by Oktay Köseoğlu, Pexels

Over the last 2 years, WHO member states have discussed sustainablefinancing. In May 2022, they agreed in principle to increasing assessed
contributions so they would cover 50% of the core budget by 2030–2031 atthe latest. This has shifted budget planning. The proposed program budget
2024–2025, for example, assumes a 20% increase in assessed
contributions, per a recent WHO financing report.)
Last year, the World Health Assembly, adopted the recommendations of theWorking Group and asked the Secretariat to “explore the feasibility of areplenishment mechanism to broaden further the financing base, inconsultation with Member States and taking into consideration theFramework of Engagement with Non-State Actors”. The feasibility of areplenishment approach is in response to this request.
The decision to pursue a replenishment approach, flows from a setof recommendations from the Working Group of Sustainable Financing. Thiswas followed up by a more focused efforts deliberating on financing andgovernance matters at WHO, through the Agile Member States Task
Group on Strengthening WHO's Budgetary, Programmatic and Financing
Governance.
Christoph Benn, Director for Global Health Diplomacy at the Joep Lange
Institute in Geneva told us, “I very much welcome the WHO initiative tolaunch a formal WHO Investment Round. WHO needs increased, sustainable
and very importantly predictable funding to fulfil its multiple central roles inglobal health. The current funding is completely insufficient and is covering
only a small part of the core budget making it very difficult for theorganization to plan its activities and attract the professional staff they need.
The agreed increases in assessed contributions are a welcome step in the right
direction but needs to be complemented by a concerted effort to reach out toall member states to commit to predictable contributions over and above theirACs to cover the full program budget that WHO needs in the next few years.
WHO will have a unique opportunity to leverage the trust it enjoys withmember states to work towards a pledging moment in 2024 gradually moving
away from multiple small grants to predictable multi-year commitments.”
Benn, was a member of the inaugural board of the Global fund to fight AIDS,

Tuberculosis, and Malaria in 2002 and also served as its Director of External
Relations during from 2003-2018
The principles to guide a replenishment process for WHO, recognizes theuniqueness of WHO’s role in global health. According to what was agreed bymember states during these deliberations last year, “any WHO replenishment
mechanism, with relevant rules of procedure, should be based on thefollowing principles: (i) is Member State-driven and approved by the Health
Assembly and open to all donors that comply with the Framework ofEngagement with Non-State Actors; (ii) addresses both WHO needs forflexibility and donor needs to show accountability for results to their own
constituents; (iii) ensures efficiency and no competition between different
parts of WHO; (iv) aligns with the defined needs of WHO as approved by its
governing bodies and is oriented to prioritize the financing needs of the basebudget in all its components; (v) aligns with the global health architecture
avoiding competition with other global actors; (vi) aligns with resolutions
and decisions of the Health Assembly.”

A NEW APPROACH
The WHA will consider a new way for the organization to raise money for its
myriad activities. Some argue the new approach could be a game-changer
that will give WHO greater spending latitude on its own priorities. Others
worry it will impinge on countries’ ability to set the agenda, opening the door
for greater say from private actors.
Next week, the WHA will consider the new fundraising strategy, areplenishment mechanism similar to those of The Global Fund and Gavi –The Vaccine Alliance, while taking into account WHO’s unique role inglobal health as a member-state driven organization. This approach would
involve a multiyear commitment from new donors to finance the WHO’score program budget. The proposal calls for a pledging event in 2024 for the2024-2028 WHO budget.
It is understood that the replenishment funds would raise voluntary
contributions for parts of the WHO’s budget not covered by assessedcontributions. Sources told us that funds from replenishment would coverwork by country offices, regional offices and headquarters across all strategicpriorities.
Typically, the base segment of the WHO budget caters to the realization of
the General Programme of Work that entails the following Triple Billiontargets: 1 billion more people benefitting from universal health coverage; 1billion more people better protected from health emergencies; 1 billion morepeople enjoying better health and well-being; as well as a pillar on more
effective and efficient WHO providing better support to countries.
As a reference, costs associated with the current General Programme ofWork supported by the core WHO budget were pegged at US$12–14 billion
over 4 to 6 years, health financing experts in Geneva say.
THE REPLENISHMENT PROPOSAL:

What is being proposed is the following: a multiyear commitment from new
donors to full-financing the base segment of the WHO’s program budget(WHO programme budget is composed of base, polio eradication andemergencies segments). The basis for this ask will be a new General
Programme of Work.
To underscore the unique nature of WHO, as the UN’s only technical agency,
the nomenclature suggested for this financing mechanism is “WHOinvestment rounds”. As a member state driven organization, countries sign
off on WHO’s General Programme of Work and its programme budget. A
pledging event is being proposed for 2024 – the first WHO investment roundwill cover a period between 2024-2028 according to the documents that will
be considered by the Assembly next week. Also envisioned is an investors
forum to catalyse the process of raising finances.
The replenishment proposal emphasizes immediacy and urgency in launching
this process. The document prepared by the secretariat suggests:“Recognizing that some global health funds are already planning to holdreplenishment activities in 2025, and in keeping with the principles adopted
by Health Assembly, the pledging event for the first WHO investment roundwould be held in the second half of 2024. In addition to avoiding competition

with the replenishment plans of other organizations, starting immediately
underlines the urgency of the health-related Sustainable Development Goals
and accelerates progress towards the Member States’ goal of sustainablefinancing of WHO. Together with the expected increases in assessed
contributions, the first WHO investment round would facilitate early and full
implementation of the draft Fourteenth General Programme of Work. Thistiming would require a decision by the Seventy-sixth World Health Assembly
for the Secretariat to proceed immediately with a WHO replenishment
mechanism, the development of that proposed General Programme of Workas the strategy on which the first WHO investment round would be based, theelaboration of an associated investment case, the design andoperationalization of the round itself, and the establishment of an investors’
forum.”THE SIZE OF THE ASK: THE NEW GENERAL PROGRAMME OF
WORK

The replenishment proposal suggests:“…The target funding envelope for the first WHO investment round would bebased on the financing envelope for the four-year period of the Fourteenth
General Programme of Work while accounting for the expected increases inassessed contributions during that period, maintaining the existing financing
flows for special programmes and optimizing complementary WHO financing
mechanisms for health emergencies and outbreaks, including WHO’s
Contingency Fund for Emergencies and its annual Health Emergency
Appeal. Specifically, the target funding envelope will be comprised of thefour-year base budget for the Fourteenth General Programme of Work, lessthe anticipated increases in assessed contributions. In parallel, a WHO
investment case will be developed to provide a prospectus of theprogrammatic returns from investing in the Fourteenth General Programmeof Work.”
AN INVESTORS’ FORUM

To raise funds, WHO is calling for investors’ forum to support the first WHO
investment round.

“The forum would initially bring together WHO’s financial contributors,including Member States and non-State actors, to discuss the draft
Fourteenth General Programme of Work strategy and results, and tounderstand and build support for the funding envelope. Following the firstpledging event, the forum would provide an annual opportunity to review thestatus of implementation of the Fourteenth General Programme of Work,showcase the results achieved with the investments that had been made todate, and discuss the future financing situation. The WHO investors’ forum
would also provide an opportunity to share experiences and lessons in orderto further improve the quality and sustainability of WHO’s financing.
Furthermore, the forum could provide a mechanism for Member States andother major contributors to have a more detailed discussion on specifictopics with staff members from the three levels of the Organization.”
The plan is to leverage the WHO Foundation to raise resources. The
document says: “With respect to contributions to the first WHO investment
round from the private sector, corporations and high-net-worth individuals,
these could be mobilized and managed by the WHO Foundation. The WHO
Foundation could in turn represent the interests of such contributors in theWHO investors forum.”
The proposal takes cognizance of funding constraints of not only memberstates, but also non-state actors.
It suggests:“With respect to existing and potential non-State actor contributors to WHO,
Member States noted that several philanthropic foundations and global
health funds have limited mandates which constrain their ability to provide
fully-flexible funds. Consequently, longer-term pledges to thematic areas ofinterest could allow such non-State actors to contribute within theconstraints of their mandates. Furthermore, the establishment of a WHO
investors’ forum could provide an opportunity for non-State actor
contributors to engage with Member States and the Secretariat more
substantively during the development of the Fourteenth General Programmeof Work and its financing envelope, and subsequently in reviewing the statusof its implementation and the impact of their contributions.”ALLOCATION OF FUNDS

The replenishment proposal says, “On the allocation of flexible funds, theprimary aim will continue to be the full implementation of the Programmebudget approved by Member States. In effect, this means having appropriate
levels of financing of all major offices and programmes (“greening theprogramme budget heatmap”) as much as possible given the available funds.
In the event that this is not fully feasible, the allocation of funds will beprioritized in line with the new allocation strategy outlined in the Programmebudget 2024‒2025 whereby resources will be strategically directed towards
Member State-directed high-priority outputs, with key outputs at the country
level to be funded first.”
ACTIONS FROM THE WHA

The proposal seeks an endorsement from the World Health Assembly nextweek, so that WHO can proceed with a first WHO investment round for theperiod 2025‒2028 with a pledging event in the second half of 2024; urges
countries and partners to support the first WHO investment round “with theaim of ensuring the full financing of the base budget segment of thefinancing envelope of the Fourteenth General Programme of Work, 2025‒2028”.
It also requests the DG to develop the target funding envelope for the first
WHO investment round, establish a road map for implementing the first
WHO investment round, culminating in a pledging event to be held in thesecond half of 2024, and to convene a WHO investors’ forum. The DG isalso being asked to consult with countries to develop the draft Fourteenth
General Programme of Work, 2025–2028. (This is expected to replace
Thirteenth General Programme of Work, 2019–2025 one year early.)

RISKS?
The benefits of the replenishment mechanism include much-needed resources
for WHO, but the downsides are that it would come from a select group ofdonors. Critics fear this could mean that non-state donors could eventually
secure a spot in the formal governance processes of WHO, which has been
the exclusive domain for member states.

When the proposal for a replenishment mechanism was first pitched at theWHO’s Executive Board meeting earlier this year, countries didn’t register
any serious objections. Many are loathe to pay more to WHO.
Even so, countries such as the US, among others have emphasized the needfor efficiency and streamlining WHO financing. (Matters emanating from theWorking Group on Sustainable Financing [Secretariat implementation planon reform]: WHO)