Big Decisions Loom for Global Health at the 78th World Health Assembly

Five years ago, as the world grappled with the earliest stages of the COVID-19 pandemic, the World Health Organization (WHO) stood in the center of the storm. By May 2020, cases were in the millions, fatalities were growing globally by the day, and vaccines had yet to be developed. In the race to save lives, WHO led the charge — researching transmission patterns, producing comprehensive technical guidance for countries, and launching task forces to coordinate and scale up the global response to slow the virus’ rapid spread.

Multiple independent panels of experts later affirmed that WHO’s actions during the height of the pandemic were critically important. Together with partners, WHO delivered over 1 billion COVID-19 vaccines and 110 million diagnostic tests and significantly increased, from 103 to 167, the number of Member States with genomic sequencing capability to detect COVID-19.

The same independent panels also found that improvements were needed to strengthen global coordination before the next disease outbreak. Among over 300 recommendations, experts urged Member States to develop new legal approaches to manage pandemics. They also expressed special concern about WHO’s fickle financing and recommended broadening its donor base and reducing its dependence on a small handful of large donors, to ensure that the organization is better positioned to respond to future health crises. Since then, the secretariat and all 194 WHO Member States have taken crucial steps to act on these recommendations and fortify the organization against contemporary challenges.

At this year’s Assembly in May, two critical post-pandemic reform processes will cross important milestones. After over three years of negotiation, Member States will have the opportunity to adopt a new legal agreement on pandemics, a breakthrough that will affirm the continued value of global cooperation under WHO’s auspices. At the same time, they’ll decide how to handle WHO’s continued financial fragility, reflected in a $2.5 billion budget shortfall between 2025 and 2027. Through the World Health Assembly, Member States will make decisions that will have real implications for how the organization can carry out its mandate with roughly just 80% of the necessary budget.

Pandemic Accord Agreed in Principle

Strengthening the legal architecture to improve pandemic prevention, preparedness, and response has been a priority for governments in the wake of the COVID-19 pandemic. WHO Member States recently concluded over three years of intergovernmental negotiations on a new Pandemic Agreement. The negotiation process, initiated by Member States at a special session of the World Health Assembly in December 2021, overcame a swirl of mistrust and misinformation to forge a new international legal instrument. The agreement, now set to be adopted by the World Health Assembly in May, represents a key milestone, though not the last step in its formation and acceptance by Member States.

Through the agreement, Member States are committed to working together to prevent pandemics through a One Health approach, including risk assessment of animal-to-human transmission — the most likely source of potential pandemic pathogens. Countries also agree to cooperate on taking steps to prepare for future pandemics by investing in public health infrastructure, service delivery, and the global health workforce. And central to the agreement are commitments to ensure an effective and equitable global response to pandemics, taking into account lessons learned from the COVID-19 pandemic. These efforts focus on improving access to essential health medicines and technologies, especially for low- and middle-income countries, even as the result of negotiations under the response pillar is deemed by some experts to have fallen short of its full potential.

Countries will decide at the Assembly how to move toward the next steps in the process, which will include further negotiations on the Pathogen Access and Benefit Sharing system, a technical annex to the agreement. PABS is envisioned to enable countries to access biological samples and genetic sequence data. This kind of sharing enables global surveillance, risk assessment, and the research and development of pandemic-related products. The secondary negotiation on PABS will require both scientific knowledge and skilled diplomacy. It is expected to take at least one year, and only once it’s complete can Member States move to ratify the accord.

Financing at the Forefront

WHO’s funding model has historically required the organization to fundraise on a rolling basis to implement its program of work. While it is not unusual for the organization to start a two-year budget cycle with limited funds in the bank, WHO’s budget deficit will be a major focus during the Assembly. Over the past few years, Member States have pursued a range of policy options to improve the predictability of WHO’s financing base, including through incremental increases in membership dues (assessed contributions) and new pathways for raising additional, flexible funds (voluntary contributions).

Two years ago, Member States decided to increase their membership dues to WHO by an initial 20%. This was a strong signal of support for the value of the institution, which monitors 100,000 potential health threats across the globe each month. As a result of the increased dues, WHO has $320 million more in fully flexible funding than it did at this time in the last budget cycle. At the Assembly in May, Member States will have another opportunity to reinforce their support for WHO by agreeing to the next incremental increase in membership dues.

Additional resources have also been generated through the WHO Investment Round effort, a novel financing mechanism that allows Member States and philanthropic donors to provide voluntary funds that are more flexible and predictable. By increasing assessed and voluntary contributions through these approaches, WHO has already secured over half of the funding needed to implement its strategy for 2025–2028. This represents important progress on WHO’s persistent financing challenges and is evidence that Member States and other donors recognize the high return on investment in WHO. For every dollar invested, the world realizes $35 in health gains.

Preparing for a Bleak Funding Forecast

While this is a relatively strong financial position compared with recent budget cycles, the prospects for raising the remaining resources in the years ahead are increasingly bleak. The United States’ planned withdrawal from the organization under the new administration, as well as anticipated reductions in official development assistance (ODA) from other donor countries, has significantly altered the funding forecast.

At WHO’s Executive Board meeting in February, Member States made the difficult decision to reduce the budget envelope from $5.3 billion to $4.9 billion for the 2026–2027 period. Subsequently, the secretariat called for a further reduction to $4.2 billion due to the anticipated decline in ODA. Like any organization grappling with a 21% decrease in budget, WHO is assessing options to reduce spending and identify efficiencies. Among the options: trimming staff at all levels, merging divisions, and relocating program activities out of headquarters in Geneva to regional offices where public health relevance is highest and operating costs are lower.

In late April, the secretariat presented Member States with a proposal to restructure staff and activities. It proposes that work at headquarters in Geneva be based around three technical divisions: Health Promotion and Disease Prevention and Control; Health Systems; and Health Emergency Preparedness and Response, with crosscutting support from the Office of the Chief Scientist and the division of Business Operations. There are also proposals to reduce the senior leadership team at headquarters from 12 to seven, and the number of departments will be reduced by almost half, from 76 to 34. WHO’s regional offices are finalizing their structures, which will align with headquarters.

Discussions about restructuring will remain active ahead of the Assembly when Member States are expected to decide on the path forward.

Advancing Key Global Health Priorities at WHA78

Apart from the high-profile discussions on the budget and the Pandemic Agreement, the upcoming Assembly will tackle an agenda that includes other global health priorities, from cervical cancer elimination to mental health promotion to operational responses to 42 ongoing health emergencies, including 17 severe health crises now underway. Member States will receive updates from the secretariat on services uniquely delivered by WHO for the benefit of all countries, such as their normative work producing global health trend assessments, and ensuring the safety and efficacy of medicines and vaccines.

Through the Assembly, Member States are expected to adopt several resolutions, including one on strengthening health financing globally. The resolution makes timely commitments to align policies and priorities to address fragmentation in health financing systems, and to provide a path toward a joint long-term vision of domestically financed health systems — in line with the Lusaka Agenda.

The World Health Assembly is always a consequential week for global health policy and practice, and the 78th Assembly feels especially so. WHO Member States and the secretariat will determine how to navigate a rapid transformation brought on by unprecedented financial pressures and will make big decisions about managing critical, lifesaving priorities with a reduced budget. But the newly minted Pandemic Agreement is a hopeful contrast to that storyline, offering an important symbol of countries’ willingness to co-create new solutions to complex global health challenges both now and in the future.