Tedros triumphant as US lays down conditions for WHO sustainable financing

Tedros Adhanom Ghebreyesus at the WHO executive board meeting on Tuesday after his nomination for a second term was confirmed. (Credit: WHO)

Tedros Adhanom Ghebreyesus received overwhelming support on Tuesday for his nomination to lead the World Health Organization (WHO) for a second term, despite earlier complaints from Ethiopia. 

As the only nominee put forward by the 34-member executive board, Tedros is guaranteed to be re-elected at the next World Health Assembly in May.

All WHO regions expressed their support for his nomination including the African region, which commended the global body for its clear nomination process. The message was delivered by a representative from Burkina Faso, a country in limbo since a military coup on Sunday night.

Last week Ethiopia – which nominated him four years ago – had taken exception to their former health and foreign minister’s criticism of the war and its handling of the Tigray people, however, the note sent by the country to the board was not considered. 

As part of the nomination process, Tedros gave an hour-long address to the board and answered a number of questions. 

During his address, he appealed for “assessed member state contributions” to cover at least half of the WHO’s roughly $3.5 billion a year budget. At present, assessed contributions (fees based on countries’ GDP) account for less than 20 per cent of the budget, with the remainder coming from voluntary contributions that are usually earmarked for particular issues, preventing flexibility and equitable regional distribution, said Tedros.

Financing dominated the second day of the board meeting, with Germany’s Bjorn Kummel, chair of the Working Group on Sustainable Financing (WGSF) describing the global body’s finances as “rotten and unsustainable for the future”.

Read also: Meet the chair of WHO working group tasked with tackling funding woes

In the run-up to the board meeting, Kummel’s group failed to reach consensus on the proposal that at least half of the WHO’s budget should come from assessed contributions. 

The board agreed on Tuesday to extend the group’s mandate until May in the hope that a contribution formula can be agreed on. The US and Japan are holdouts on increased member contributions unless the WHO guarantees to improve its financial governance.

During afternoon proceedings, US representative Loyce Pace called for a “holistic package of measures” to ensure WHO sustainable finance, that included improved governance and transparency on “current funding mechanisms, prioritisation, budget processes, improved cost efficiency and early member state inclusion in the decision-making processes”.

When Japan asked Tedros how he was going to reform WHO’s financing, particularly “accountability and transparency and financial discipline”, Tedros asked for the country’s support to increase members' assessed contributions.

He explained that under his leadership voluntary contributions had risen from around $14m in 2017 to almost $260m - but no progress had been made on increasing assessed contributions.

However, he later assured members that he was committed to increased accountability and transparency, and would deliver this.

Transformation plan – where has it led? 

Shortly after taking office, Tedros undertook a massive transformation plan for WHO aimed at making the organisation more transparent and responsive to the needs of member states, and with more “leadership” in developing regions and countries. 

However, Covid-19 forced the WHO to shift focus from internal reforms to responding to an immediate crisis, while a temporary halt in US funding under former US President Donald Trump sparked a short-term financial crisis. 

A key element in the transformation plan, to move more funding and positions to WHO’s six regional and 152 country offices was stymied by the pandemic. 

It also cut short a new WHO system of more regular rotations of staff in and out of headquarters to regions – along the lines of diplomatic missions – to which there was already considerable staff opposition pre-pandemic.

As a result, WHO is falling short of what has been a decades-long target for a 75-25 per cent split of its budget between regions and headquarters with over 30 per cent of the total budget being spent in headquarters today.

This goal was surpassed in 2016/7, the last budget cycle before Tedros took office, when 84 per cent of the budget was spent in regions, and only 16 per cent at headquarters.  

The net result is a persistently under-financed African and South-East Asian regions – which generally host the biggest disease burdens in the world. The African Region only gets 22 per cent of WHO funding – although that is supplemented by direct bilateral support from the US and other donors through channels like PEPFAR – the US HIV/AIDS relief plan which has been a backbone of HIV/AIDs battle since 2003 – funneling some $10.8bn into AIDS programmes – and hybrid Aids/Covid efforts in 2021. 

The Western Pacific (including China, Pacific Island States, Australia and Japan) receives only 4.28 per cent of funding. The South-East Asia Region gets six per cent – about the same as the European Region – whose budget is also self-financed by EU member state contributions. In contrast, the conflict-wracked Eastern Mediterranean gets 26 per cent of the WHO programme budget. 

The Americas region gets the least, less than three per cent – although WHO support is massively supplemented by the US and other North American donors that fund the powerful Pan American Health Agency (PAHO), as a semi-autonomous agency.  

Not without reason, however, responding to health emergencies has also consumed a huge portion of WHO’s recent budget – some 41 per cent of resources in 2021.

Over-dependence on short-term consultants 

As things stand now, WHO insiders say that the body is overly dependent on short-term consultants that it parachutes into jobs. Approximately a quarter of WHO staff are on short-term contracts, according to insiders.

The net result is an organisation that lacks a stable backbone of fixed term professional staff – from entry to senior levels –  that can dare to take unpopular positions and assume leadership roles. 

That, along with a weak internal justice system, which was the focus of complaints at last May’s World Health Assembly have also reinforced what some WHO insiders describe as the “authoritarian” tendencies in Tedros’ leadership style and the DG’s office – which also have diminished the authority and the roles of his assistant director generals – who are politically appointed.

This article was published in collaboration with Health Policy Watch.