The case for investing in WHO

The Lancet
Sep 29, 2018 Volume 392 Number 10153 p1089-1166 e8-e9

The case for investing in WHO
The Lancet
“This is not about only investing in an institution, it’s about investing in people, it’s about investing in a healthier, safer, fairer world”, said Director-General Tedros Adhanom Ghebreyesus at the launch of WHO’s first ever investment case. These emphatic words set the tone for an ambitious goal: to make the case for the investment needed to deliver WHO’s 5-year strategic plan, approved earlier this year—the 13th General Programme of Work, 2019–2023 (GPW13). That WHO is articulating its investment case is unprecedented and welcome. WHO’s work on global public goods (eg, norms, standards, and technical guidance) is more important than ever and is seriously under-appreciated by development partners.

If funded sufficiently, WHO believes the GPW13’s so-called triple billion targets—based on three interconnected priorities: 1 billion more people achieving universal health coverage (UHC), 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and wellbeing—could be achieved by 2023. The investment case states that WHO, in joint action with member states and its partners, could save up to 30 million lives, add more than 100 million healthy years of life to populations worldwide, and stimulate 2–4% of economic growth in low-income and middle-income countries by 2023. The only conditionality is money. As previously estimated for GPW13 in May, 2018, to achieve these goals, the investment case estimates that WHO needs US$14·1 billion from 2019 to 2023, which includes a $10 billion base budget, $2·5 million for humani-tarian aid and emergencies, and $1·6 billion for polio eradication. WHO calls on donors for flexible and multiyear funding, the absence of which has impeded its capabilities and commitments. WHO’s current projected income is $4 billion, leaving the agency with the huge task of raising $10·1 billion for the next 5 years.

At first sight, this investment case seems compelling. An investment brochure describes the indispensable work done by WHO to support countries and improve the health of populations worldwide. It lays out a clear and valid strategic direction: to provide leadership, to ensure country impact, and to deliver global public goods. WHO will focus on activities in five specific key health areas, which support achieving the triple-billion targets: human capital, non-communicable diseases, high-impact communicable diseases, antimicrobial resistance, and healthy environment. Surprisingly, the case provides little concrete detail about how WHO will use these funds to deliver on its stated goals. Perplexing is the disconnect between the claims of impact in the investment case and of those in the accompanying technical report, which estimates the health impacts and economic returns for universal health coverage (UHC), health emergencies, and intersectoral action based on a collective global investment—and not for specific investments in WHO. Thus, the UHC return of 25·1 million deaths averted is based on a global investment of $1·1 trillion as set out in the technical report. However, the WHO investment case seems to suggest that investing $14·1 billion in WHO alone will generate these returns. The technical report seems to bear little relation to the investment case for WHO.

A valuable contribution of the investment case would have been to clearly articulate what WHO will actually do in its three priority areas and where its comparative advantage lies: global public goods and normative work, emergency preparedness, and support to countries in developing the health policies needed to achieve the Sustainable Development Goals (SDGs). At a time when WHO is competing for limited donor resources against other institutions, such as The Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, The Vaccine Alliance, a clear explanation of how additional investments will deliver the goals set out in the investment case seems crucial. A more precise analysis could have made the case for a chronically underfunded but desperately useful and overlooked part played by WHO: that of providing global public goods, which need to be reinforced to reach the SDGs and respond to old and emerging global health threats.

WHO’s historic and institutional strengths lie in responding to the urgent needs of its member states. But during the past decade, WHO’s budget has been tied to donor conditionalities and has failed to grow in real terms. Therefore, it is right that WHO is calling on donors to strengthen the agency’s global, regional, and country capacities to take advantage of the opportunities that exist for improving human health. Sharpening the investment case still further will go a long way to fulfil that opportunity.

13th General Programme of Work (2019-2023) see White paper 2018