WHO’s Fairy Dust Financing

With the world now facing epidemics of yellow fever and Zika virus, both of this week’s high-powered gatherings of the G-7 leaders in Ise-Shima, Japan, and the annual World Health Assembly in Geneva had outbreak control placed high on their agendas. But it will take a lot more than minor reorganization and promises of cash to bring the World Health Organization (WHO) and its 194 member nations up to readiness status for these and future epidemics. That kind of preparedness begins with leadership and mutual trust between the institutions of public health, political leaders, and the populations they are supposed to serve. This is a feat that WHO has not, by any measure, accomplished.

WHO is governed by its World Health Assembly, which convenes at this time every year in Geneva to debate a laundry list of resolutions aimed at improving the survival and health of billions of people. One key resolution the assembly has refused, for nearly four decades, to bring to the floor for debate or vote is money — how much individual nations must pay in annual assessment to support WHO. The assessments, which are based on national GDP and population, fairly place the greatest burden on the wealthiest countries, with the United States paying the most. But because the assembly has declined to even entertain an increase in annual assessment rates for nearly four decades, when adjusted for inflation, the WHO core budget has steadily declined.

For years, the drop in core funding for WHO has been offset by so-called voluntary contributions — extra-budgetary funds provided by wealthy nations and organizations now exceeding the agency’s core budget by 75 percent. Combined, the Bill and Melinda Gates Foundation and the U.S. government account for 23 percent of WHO’s total core and voluntary budget, which amounts to $4.4 billion for 2016 and 2017. Members of the assembly have long complained about the disproportionate influence Americans have on WHO but have been unwilling to provide a financing mechanism for the institution that spreads the pain more broadly. In its current gathering in Geneva, the assembly is continuing this woeful pattern, trying to block nasty American meddling in global health affairs, while refusing to entertain any other mechanism for generating billions of dollars a year for WHO.

Worse, for the last two years, the assembly has added the equivalent of fairy dust to the mix, voting for budget increases but then leaving it up to Director-General Margaret Chan to mysteriously conjure up the agreed-upon additions. In 2015, the assembly, stunned by performance failures in the West African Ebola epidemic, approved the creation of a $100 million special WHO fund for combating outbreaks — but left it up to Chan to find those millions of dollars. She was able to cobble together about 30 percent of the money and hopes someday to find the remainder. On Feb. 1 of this year, Chan declared a public health emergency of international concern over the widening Zika crisis and said WHO needed $25 million to fight the mosquito-borne disease. More fairy dust: No donors stepped up to sprinkle real cash on the Zika crisis, so Chan moved $3.8 million out of her not-yet-fully-funded “$100 million” epidemic fund into a new “$25 million” Zika account.

Even if Chan managed to gather tens of millions of dollars, that money would have to be spent in miraculous ways to offset the costs of genuine epidemics. According to the World Bank, it was donors who eventually ponied up the $7 billion used to combat the West African Ebola fiasco, $2.8 billion of that coming from the coffers of United Nations agencies.

This week, the assembly added more fairy dust delusion to the mix, resolving to consolidate several small outbreaks, surveillance, and crisis response branches into a single new Health Emergencies Program, giving it an annual budget of $494 million. While that might seem like a step forward, the reality is this: $334 million of that is a real money-in-the-bank commitment, but $160 million is more fairy dust that the assembly is giving Chan permission to go out and find.

Fairy dusting is all the vogue these days for epidemic prevention and control. The Republican-controlled U.S. House of Representatives responded to a White House request for $1.9 billion in Zika emergency funds by granting $622 million, none of it new money: $352 million will be removed from previously committed Ebola and global disease detection silos and another $270 million robbed from the Health and Human Services Department, where it is currently being used to administer the Affordable Care Act, or “Obamacare.”

Fairy dust.

More fairy dust is flying at the World Bank, where this week a $500 million Pandemic Emergency Financing Facility was announced, which, through unknown mechanisms, will decide when and where to allot funds to fight outbreaks. The money for the not-actually-funded facility, according to a World Bank brief, will be “financed through two windows, insurance and cash. Funding under the insurance window will be provided by resources from the reinsurance market combined with the proceeds of catastrophe bonds (capital-at-risk notes) issued by IBRD, and will provide a maximum coverage of [$500 million] for an initial period of three years. Development partner contributions will cover the cost of the premia and bond coupons for the insurance window. To complement the insurance window, a cash window will provide more flexible funding to address a larger set of emerging pathogens which may not meet the activation criteria for the insurance window.”

The G-7, representing the major industrial nations, is also responsible for dusting the epidemic terrain with fairy dust. At the opening of last year’s World Health Assembly, German Chancellor Angela Merkel gave a strong speech about the need for massive WHO reform, dramatically improved world capacity to recognize and swiftly respond to outbreaks, and the need for an enormous fund to support those changes. But when the Schloss Elmau G-7 summit ended last June, there were no concrete pledges of yen, dollars, euros, or pounds. Fairy dust.

This week’s Ise-Shima G-7 summit also calls for WHO reform, improved epidemic responses, and funds to support them. The Shinzo Abe government has gone a step further than Germany did last year, committing to donate $1.1 billion over the next three years to a list of global health programs. But none of the other G-7 members has offered, in advance of the summit, similar support.

Times are tough, and most global wealth is locked up in private funds far from tax collectors or in direct government and corporate commitments. Still, the expenditures needed to bring an epidemic under control after many lives have been lost are exponentially higher than those needed to bring microbes under control during the initial stages of an outbreak.

One low-cost item that could cut through the fairy dust would involve changing how WHO chooses its next leader. Candidates are now officially announcing and igniting their campaigns for ascendancy to the WHO throne in July 2017. Under a new, unprecedented process, the candidates for director-general will plead their cases to members of the 34-member Executive Board between now and January 2017. The board will select three of the candidates, who will then campaign vigorously all over the world for five months. Then, for the first time in its history, the World Health Assembly will vote directly, choosing a new leader in a “one country, one vote” manner that gives the tiny Pacific Island nation of Niue an equal vote to behemoth China. The votes, delivered by ministers of health from respective nations, will be filed by secret ballot. Therefore, there will be no accountability or transparency in the voting process; citizens of the world will not know how their country voted; and the tiniest countries will out-vote the 13 most populous ones that, combined, represent 60 percent of the human population.

The process stinks and is unlikely to produce a new leader fit to lead WHO and stand at the helm of the next pandemic. No, it can only make more fairy dust.

Photo credit: STAN HONDA/AFP/Getty Images