Pandemic Proof: Funding the WHO for Pandemic Preparedness

Catharina Boehme: Our goal in a summary is very simple. It's funding that's predictable, flexible and diversified, because we cannot keep firefighting with funds that arrive only when the fire has already started. This can make a huge difference for global health security going forward.

Javier Guzman: You are listening to Pandemic Proof from the Center for Global Development. In this podcast, we explore policies and reforms to better prepare and respond to infectious disease threats like COVID-19, but also other nasty viruses, microbes and fungi that can throw our health, our communities and our economies into crisis. Join us as we envision ways to better protect our world in the future. I'm your host, Javier Guzman. This episode will be guest hosted by my CGD colleague, who is an expert in this field. Now, let me turn it over to them.

Pete Baker: Hi, everyone. I'm Pete Baker, Deputy Director of the Global Health Policy Program here at CGD. I'm very excited to be hosting Pandemic Proof today on such an important topic as WHO financing. The World Health Organization is the beating heart of our global health system, representing the collective effort of 194 countries to protect and promote our health. The current state of WHO funding, however, significantly hinders its ability to deliver on its mandate and promptly respond to crisis, outbreaks and pandemics.

In response to this, last year, member states made a historic agreement to increase the provision of flexible funding known as Assessed Contributions. In 2024, WHO launched its first ever Investment Round, aiming to secure an additional $7.1 billion for its 14th General Program of Work, covering the period from 25 to 28. The Investment Round culminated at the G20 Summit in Brazil in November, and so far it has received pledges of approximately $1.7 billion, which does actually make up to a total of $3.8 billion, with expected funding from other sources such as partnerships and agreements.

These funds raised are really essential for the WHO, but it's far below what was hoped for, and the specter of cuts by the incoming Trump administration looms large on the horizon. Importantly, it's still unclear how much of these committed funds are truly flexible. This lack of flexibility could continue to hamper the WHO's ability to set priorities and act fast, which are two key pillars of pandemic preparedness and response.

Within this context, I'm really delighted to have joining me today, Catharina Boehme, Assistant Director General for External Relations, Partnerships and Governance at WHO, to discuss the outcomes of the Investment Round and the opportunities and risks it presents for strengthening global health and pandemic preparedness. Catharina, it's really great to have you here today. Thank you so much for speaking with me.

Catharina: Thank you so much, Pete, and I'm really happy to have the opportunity to be here with you today.

Pete: Thank you. Perhaps we could start with a bit of history and context. Prior to this year's Investment Round, how would you describe how WHO is financed for pandemic preparedness, and how did this differ from other areas of routine expenditure? Can you offer some reflections on how this model had some challenges that were highlighted by COVID and the impacts?

Catharina: When I started working for WHO early 2021, really at the height of the pandemic, I was surprised, if not almost shocked, at how the organization was financed and at what a great job it did despite its weak state of financing. Just to give you the picture briefly. Firstly, WHO operates and operated on an annual budget equivalent to that of Mount Sinai in New York, approximately $2.1 billion per year. This budget funds our entire workforce and all the activities, not only at headquarters, but also in the regions and in our 154 country offices.

The only additional budget is basically our health emergency appeal funding. Even that can only be implemented with the help of the core staff. That again is funded from this base budget, as we call it. When I arrived in 2021, what I found was only 16% of the WHO funding came from so-called assessed contributions, i.e. the membership fees. 84% of the funding came from voluntary contributions from various donors.

The vast majority of these voluntary contributions, over 70% actually, came from just 10 donors. Not diversified and resilient at all. Over half of these voluntary commitments were just one-year commitments and thousands of grant reports had to be written every year. That resulted in significant inefficiencies in the inability to address country needs and serve with high quality, especially in Africa and Asia, which were consistent pockets of poverty, as we call them.

Our pandemic preparedness and also response efforts were particularly affected by these financing flaws. Pandemic preparedness historically has not been an attractive area for funding and has always been an underfunded area. That briefly changed during COVID, but since then we've re-entered a period of neglect for funding pandemic preparedness.

What happened during COVID was that it became very visible that many or most countries had inadequate surveillance capacity, inadequate lab capacity, very weak health systems and clinical capacity to respond. This led to very delayed public health responses, especially at the onset, but throughout basically of the COVID-19 pandemic. Member states became acutely aware of our funding situation during the pandemic and sent a powerful signal to the executive board in January 2021 that the WHO funding situation had to change.

That was the beginning of our sustainable financing journey. We've been accompanied by member states, by our donors along the way. It's taken us to Rio, where we had many world leaders express their support to our investment round and to our sustainable financing journey. That journey is far from over. It's, we're really in the midst of it.

Our goal in a summary is very simple. It's funding that's predictable, flexible and diversified because we cannot keep firefighting with funds that arrive only when the fire has already started. This can make a huge difference for global health security going forward.

Pete: Thanks, Catharina. It's really interesting to hear the challenges. I'm particularly picking up on how you're saying that during the COVID pandemic, the WHO was to some extent held back by a lack of funding to inflexible funding and perhaps a narrow funding base from too few donors. How do you think then, with that in mind, the sustainable financing working group and the resolution that came from that and this investment round, do you think it really addresses these challenges and how does it address these challenges? What ongoing risks do you see that are still there despite the improvements?

Catharina: Our sustainable financing journey really focuses on two areas. One is increasing the assessed contributions, and the other is to get the voluntary contribution portion more predictable, flexible and resilient. The World Health Assembly sustainable financing resolution adopted by member states in 2022 was a pivotal step and really a historical achievement, I would say. What it did was it formalized the commitment from member states to cover at least 50% of WHO's core budget by 2030 through these assessed contributions.

That's a big shift away from the reliance on voluntary contributions and we've since taken the first step increase. If we get to these 50%, it would really be a dramatic change in terms of how WHO is financed, and it would make a dramatic change for our workforce. For example, in our country offices, prior to this and even until now, a lot of the people are in constant short-term contracts, just 60-day contracts or 6-month contracts. That makes planning operational work, implementation work really difficult.

To your question, have we made progress also through the investment round? Definitely the answer to that is yes. Maybe let me just summarize this in three points. First, the investment round really helped us to enhance and drive political commitment to WHO. As I said earlier, we clearly saw a panic and neglect cycle driven by the COVID-19 pandemic, and the investment round to a certain extent was a defense strategy, because given the very challenging political situation out there in the world, the economic downturns, so we saw a lot of cuts at the horizon from donors.

It was this political commitment that helped us to bring global health back on the agenda, bring WHO on the agenda, but also the entire ecosystem of health and global health, which was really one priority of the investment round. We had an enormous total number of statements from ministers, heads of states through this year, which really showed us unprecedented commitment to global health and WHO. I would say that part has clearly been successful.

Second, flexibility and predictability. Of all the over 70 pledges we've received by now, the vast majority provides us with either fully flexible funding or thematic flexible funding. We see clear improvements there, and we estimate to have doubled our predictability. However, knowing that our predictability of funding, our visibility and plannability was at such a low starting point, that it's still far from perfect.

Since the Investment Round launched in May, we've had 70 new pledges, mainly from member states, but also philanthropy and private sector donors. Many of these pledges are first time contributions to WHO, so come from new donors, which indicates a broadening of our donor base, a diversification. What I find very remarkable within that is that 28 of these first-time pledges are from low- or middle-income countries, representing a real shift in how WHO is funded on the voluntary contribution side and shows also the significant political commitment from these member states, countries to WHO.

However, like last not least, the risk of over-reliance on a few large donor proceeds and to mitigate that, what do we have to do? I think first of all, deliver on our work, demonstrate and continue to demonstrate accountability, measure our successes, our value for money, which I think is so clear, but we don't always communicate it well and be fully transparent about what we do and how we spend our money. I think that will hopefully continue to put us up well on this journey and on its next steps, and will definitely continue to diversify.

I think there's still a lot of room to broaden the donor base on the philanthropic side, on the private sector side, but also we've been traditionally very conservative. I think there's more we can do on the innovative financing side.

Pete: It's very inspiring to hear a good news story in global health. It can be hard to come by at times, particularly when multilateralism seems at risk and shaky. Although we haven't been able to verify this, and I hope WHO will share this information in future, but that you're saying that you've got an increase in flexible funding as part of that, which is great to hear.

I also appreciate your honesty with regards to the reforms at WHO and the better communication at WHO that's needed to convince donors to get behind WHO with flexible financing in the future. I guess I just wanted to offer you a chance to reflect on the total number, because from one perspective, the total number, particularly if you take 1.7, which is the published number compared to the 7.1, it doesn't look so good. Would you like to offer any reflections on that? Was it an overambitious target?

Catharina: Yes. At this point, as of the Rio Highlight G20 Summit, we received $1.7 billion in terms of pledges. That brings our funding to a current total of $3.8 billion of the $7.1 billion we need. The $3.8 billion includes pre-existing commitments, it includes also commitments from donors that want to remain anonymous, don't want to pledge, et cetera, right? We still have a number of pledges to come in the pipeline. For us, this investment round in a way is not yet over. We still will add all the money that comes in between now and the World Health Assembly next year.

I think what was particularly remarkable also for us, and the highlight for me at the G20 Summit last week, was that President Ramaphosa of South Africa announced that they, as a champion of the sustainable financing for WHO, will take the sustainable financing agenda into their G20 presidency for 2025 and will continue to help us to raise the funding we need for our global program of work 2025 to 2028.

Pete: Turning now more directly to pandemic preparedness, how do the funds raised during the investment round to be allocated to pandemic preparedness? Particularly, how will that align with the other financing streams that you might think about? You've mentioned already the WHO Health Emergency Appeal, there's also the Contingency Fund for Emergencies, but then there's also important other mechanisms like the Pandemic Fund, the IMF's Resilience and Sustainability Trust. I'd like to hear how you see that working in practice.

Catharina: The investment round funding will be allocated against the budget developed with and approved by all member states. In other words, there's not full flexibility in how and where we put this money, but there's a pre-approved budget and the flexible funding will be allocated against that. This budget was developed based on our 2025 to 2028 strategy. This strategy very strongly prioritizes pandemic preparedness and acknowledges the criticality of preventing, detecting and responding to pandemics.

Bolstering surveillance systems, strengthening workforce capacity and filling the 10 million gap that we see in healthcare workers and equitable access to medical countermeasures will all be a central piece of our next strategy, and therefore, of the funding that will benefit through the investment round. Importantly, these funds are designed to plug gaps identified in the WHO Health Emergency Appeal and clearly complement the Contingency Fund for Emergencies, right? You'll not see any duplication there. Those are really complementary efforts.

We also avoid duplication with any other mechanisms like the Pandemic Fund or the IMF's Resilience and Sustainability Trust Fund. We work at WHO very closely with these institutions to ensure complementarity, but also avoidance of duplication, especially also at the country level. I think in so far, we are all clear. Having said this, let me perhaps add one point. We see a steadily increasing number of global health emergencies. As of October, we, as WHO, were working on 39 graded health emergencies and we see a steady upward trend.

We clearly see global health security under threat and climate change consequences are not expected to make this any better, right? I personally think these trends towards increased graded health emergencies will continue. That will mean that the funding we have available as WHO, but also the external sources you mentioned will not be enough to address the health emergencies the world has to deal with. I think going forward, we all need to work together to make sure that we continue on this path we are on, which is to strengthen global health security for everyone.

Pete: Is there any more you could say on that distinction between the pure investment round funding and your contingency fund or the Emergency Appeal or the external funds? Will this core funding have any specific focus areas regarding pandemic preparedness or is it intended not to be broad?

Partly I'm coming from this from the perspective that there isn't much money in the global health architecture at the moment. There's certainly not enough money to deliver on all those pandemic and climate change risks you mentioned. It's important for each part to get the most for the money and to coordinate well. I'd love your thoughts on that.

Catharina: Yes, absolutely. The contingency fund for emergency is really distinctly different from our base budget. What that is, is a very flexible funding mechanism that our Health Emergency Executive Director and Deputy Director General, Mike Ryan, can use within 24 hours to basically give to a country that has a very acute crisis, whether it's disease outbreak or whether it's another health emergency. It allows the very early response that is very often needed and absolutely critical.

It's allowed us to be extremely fast in multiple crisis, right? Whether it's Ukraine, whether it's the recent Mpox outbreak, whether it's the cholera outbreaks that we're seeing in Africa. This is really the early funding that enables us to be agile, fast, bring commodities on the ground within a couple of days. That's not the purpose of the Investment Round at all, but the Investment Round will fund the base budget or core budget. A lot of our health emergency people, so the workforce and the people that work in pandemic preparedness and response get their salaries paid from this base budget, and is then complemented with a surge workforce. That comes from the Appeal Funding and activity funding.

Basically, the base budget is funded through the Investment Round and the assessed contributions, and that covers the core workforce that we need to respond to health emergencies, to outbreak situations.

Pete: Very nice. That makes sense, Catharina. I just wonder if you could offer any reflections on how the base budget is prioritized and allocated, because I think this links actually to two points you've made. One is convincing member states and owners to keep funding and keep funding flexibly because they believe the WHO has got good systems, but also to show that it articulates well with other agencies. It might be valuable for listeners to hear from you on what is the process by which the WHO then allocates to countries and themes.

Catharina: For WHO, this is a really bottom-up process and one-year long process to develop our budgets. It's done with our 194 member states, with all our country offices, and they prioritize their needs at the country level. A certain ministry is asked to work closely with our country offices and identify their national priorities for the next four years. This bottom-up approach of developing a budget has become now the norm and is very transparent, and transparently shared at all the regional committee meetings, and then gets pulled together from the regional budgets basically into a global budget.

Pandemic preparedness, as I said, can easily get forgotten by countries because it's not always front of mind, right? Front of mind are usually problems of clinical care, infectious disease problems. A high priority we see at the moment across member states is health systems strengthening, which has big effects for pandemic preparedness as well, for climate resilience, as well as for treating infectious disease areas. We do see that COVID, but also the more recent Mpox outbreak, for example, has really been, I would say, a wakeup call for countries. We see the prioritization of pandemic preparedness going up.

Clearly our activities and allocation at WHO have to be complemented by other mechanisms. You mentioned the pandemic fund earlier, and the pandemic fund is, for us, a very promising tool to strengthen surveillance and lab capacity. It's absolutely essential to do that and complements the domestic funding that countries bring to this area. It's not reached the levels of funding yet that it needs. Unfortunately, it's also not been additional funding as everybody hoped for, right? It's not funding that came out of the defense pockets. It's not new funding, unfortunately, truly new funding, but it would be so much needed.

That's where I personally, I'm still worried because despite the experiences that we encountered and all made during the pandemic, we've not seen any increases in funding. Now, given the economic outlook, given the multiple challenges the world faces, we see cuts in ODA funding in many, many countries. We see cuts to health funding at domestic level, but also at international level. That doesn't put us off on a great start for securing better pandemic preparedness going forward.

In those times, it's going to be even more important that we work closely with all partners and that we don't fragment ourselves further, but that we stand together and get the job done.

Pete: Exactly. With that last bit on mind, we always ask our guests one final question, which is around if you could prioritize one change in the global architecture for pandemic preparedness and response, what would it be?

Catharina: If I could prioritize one change, I think it would be to institutionalize equitable global financing for pandemic preparedness. This means establishing a binding commitment for all countries to contribute to a global health security fund based on the country's capacities, and similar to what we see in climate financing. I think from my perspective, such a binding commitment and a global health security fund would ensure fairness, would ensure sustainable and predictable funding for preparedness.

It would massively reduce the dependency that the world currently has on just a few large donors, and it would address global inequities we see currently by channeling resources to the most vulnerable regions. It would and should not draw, as I said, from the scarce ODA funding, but come from defense and security funding, because every day the world spends $7 billion fighting wars and preparing for them. We need just a tiny portion and fraction of that to make our world safe from pandemics and outbreaks.

Pete: Well, on that ambitious and optimistic note, Catharina, I thank you so much for your time and thoughts today.

Catharina: Excellent. Thank you so much.

Javier: Thanks for listening to Pandemic Proof from the Centre for Global Development. Very special thanks to the CGD podcast team, Sophia Greenhoe, Stephanie Donohoe, and Soundeazy for making it happen. Pandemic Proof is available on the CGD podcast stream, so make sure you are subscribed to the CGD podcast on Apple, Spotify or wherever you listen to podcasts. Remember, you can check out all of our work on pandemic preparedness and beyond at cgdev.org. Thank you very much.