The new WHO Foundation - global health deserves better.

The WHO plays a crucial role in global health but has had well-documented issues with funding in terms of the models of funding adopted, the size and sources of contributions and the influence of certain donors in driving specific priorities.

This year the WHO Foundation has been launched as a way to broaden the WHO donor pool. We describe a lack of clarity about the applicability of Framework of Engagement with Non-State Actors (FENSA) norms and practices to this new entity.

The risks regarding undue corporate influence at the expense of independence were at the core of the protected negotiations underpinning the development of the FENSA that guides the WHO itself, but do not appear to be reflected in the Foundations’ governance structures.

Considering past failed initiatives, and how many global health challenges, including non-communicable diseases and climate change, are driven by powerful transnational companies, the WHO cannot afford to be seen to sacrifice independence or impartiality to the commercial determinants of health in pursuit of funding.

The WHO remains a linchpin in global health not least in response to the COVID-19 pandemic. It relies on contributions from donors and member states,1 but there have been well-documented issues with the models of funding adopted, the size and sources of financial contributions and donor influence in vertically driving specific priorities,2 in contrast to the wider health governance mandate of the WHO.

Adequate resources and independence are critical and interlinked. The need to address major public health issues may conflict with vested interests such as powerful transnational companies that serve as the vectors of non-communicable diseases such as diabetes, heart disease and cancer.3 The WHO therefore needs the resources to independently and transparently intervene to improve health, prevent harm and tackle inequalities, consistent with its mission, whether the causes of poor health are natural or manmade.

This is why the recent launch of the WHO Foundation, established with the explicit intention of broadening the WHO donor pool, appears problematic. It seeks donations from members of the public, high-net-worth individuals (HNWI) and from corporations. It aims to constitute an ‘independent entity’ that can accept these funds and, in turn, support WHO activities.

The WHO Foundation thereby realises a longstanding, and highly contested, ambition within the leadership of WHO. This ambition was central to Margaret Chan’s reform agenda, with her 2011 report on future financing envisaging widening WHO’s resource base by inter alia developing ‘innovative financing mechanisms’ and drawing on ‘foundations and the private and commercial sector, without compromising independence or adding to organizational fragmentation’. Widespread concerns about the ability to reconcile WHO’s independence with increased engagement with commercial actors were at the centre of the protracted debates around developing a new Framework of Engagement with Non-State Actors (FENSA) that followed.4

While FENSA principles have themselves been criticised as insufficient to protect against conflicts of interest,5 6 concerns about the adequacy of governance mechanisms for the WHO Foundation are heightened by a lack of clarity about the applicability of FENSA norms and practices. Indeed, the logic of the Foundation suggests that its operations will extend beyond the scope and protections of FENSA in concerning ways.

The affiliation agreement signed between the WHO and the Foundation in May 2020 is clear (para 11.3) that the Foundation will not generally receive ‘funding from governments or governmental entities or philanthropic organizations that have or can provide funds directly to WHO’.7 Restricting the Foundation’s activities to donations that WHO cannot accept doubtless reflects operational and procedural issues, but also points to the potential for it to accept funding from sources that would be deemed inappropriate for WHO itself. The agreement provides little reassurance in this regard: the only sources of funding explicitly excluded are the tobacco and arms industries, and while there is a commitment to ensure that all funding ‘does not pose a conflict of interest for WHO’ (11.4) in the context of Foundation initiatives this is qualified as avoiding conflicts ‘that cannot be mitigated in coordination with WHO’. (14.2). A similar principle was espoused in an interview by the new CEO of the Foundation, who stated: ‘There will be some industries that are off limits, because it’s been important for the WHO to make clear that they keep a lack of engagement with the tobacco industry and with the arms industry, but those are typically the exceptions’.8

This narrow approach contrasts with work by the WHO and other organisations to better assess conflicts of interest in identifying suitable partnerships, such as in the context of globally consolidated food or alcohol producers, made more difficult precisely because such commercial actors have been found to actively oppose such regulatory and conflict of interest safeguards.9 10

In parallel, and remarkably given above, the Foundation has been launched, and has been accepting donations, in the apparent absence of an agreed conflict of interest policy or standard operating procedures regarding the suitability of donors. A published Q&A document states the Foundation ‘will follow FENSA principles when accepting donations and vetting donors’.11 However, FENSA principles explicitly do not offer contributors the possibility for advising, influencing or participating in the management or implementation of operational activities. This conflicts with the WHO Foundations stated intention to ‘craft individual donations’ and provides for donors ‘participating in the design of their engagement and interact with the implementing partners they support’.

Taken together, this is concerning.

In considering the likely trajectory and implications of the Foundation, it can be instructive to review the COVID-19 Solidarity Response Fund for the WHO, with which it has structural and functional similarities. Perhaps understandably given its rapid establishment, the COVID-19 Fund provides limited information on governance issues, but it does preclude accepting funding from the alcohol industry, invoking the due diligence processes of its operational partners the UN Foundation and Swiss Philanthropy (a notable omission in WHO Foundation documents). The list of corporate actors that have donated to the COVID-19 Fund, such as PepsiCo, Starbucks and global snack foods giant Mondelez International, remains concerning.12 Such donations clearly play an important legitimation function for unhealthy commodity industries, sometimes called healthwashing,13 and funding the WHO Foundation would provide corporate actors an opportunity to directly advance strategic and commercial objectives.

The justification for the WHO Foundation’s separate legal status partly rests on a claim that it can ensure independence from undue influence, by creating ‘a more credible firewall that protects WHO’.11 Yet if the Foundation is to be successful it must generate funds at a level that could threaten operational independence. It is not difficult to envisage a scenario in which donations from alcohol or ultra-processed food producers, for example, come to exceed the extremely modest provision in the WHO budget for alcohol control and obesity initiatives. And it is not alarmist to suggest that such dependence creates potential for a form of regulatory chill, particularly in the context of increasingly severe fiscal constraints, that could further jeopardise fragile commitments to advancing contested measures such as sugar taxes14 15 or regulating alcohol marketing.16

The limited accountability mechanisms provided for in the affiliation agreement seem insufficient to address such concerns. Given that the Foundation’s task is defined as ‘to maximise net financial contributions’, its Board seems incentivised to take a minimalist approach to scrutinising donations.

The use of foundations to direct such funds is not a unique arrangement. In the USA, where corporate and HNWI philanthropy play a larger role compared with Europe, both the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) have similar foundations. However, how funding is solicited, from whom and for what has important implications. The US model shows the challenges in selecting donors with interests aligned with that of the public institution. A lack of safeguards make it possible for donors with a conflict of interest to guide the activities of the parent agency in ways that favour their interests, through funding particular streams of work, and through undermining, implicitly, or explicitly, streams of work that conflict with business interests.

For example, Coca-Cola, via its funding of the CDC Foundation and the International Life Science Institute, funded research and charity projects with a focus on physical activity. Through such initiatives, Coca-Cola was able to cultivate strong ties with the CDC, and seek to undermine work on diet, including through lobbying the WHO on sugar taxes.14 Similarly, a high-profile study on the effects of alcohol on health co-funded by alcohol producers and the NIH National Institute of Alcohol Abuse and Alcoholism was found to be compromised in its development and design in ways that favoured the industry, leading to its cancellation amid public outcry.17

It is for these reasons the WHO itself has been developing conflict of interest tools to ensure that public good is not undermined by private profit. The fact that these tools provoke resistance among entities with a conflict of interest in health underlines their importance. These risks contrast with the troubling reality that the WHO Foundation is already soliciting donations, from the public, wealthy individuals and from corporations, in the absence of a clear conflict of interest policy. We were unable to identify any published policy on donor transparency, in contrast to the norms for other such organisations. Earmarked donations from corporate partners are welcomed, but the way in which such interactions are conducted, when they are assessed for conflicts of interest or how their eventual impact is measured, is not stated.

If the current pandemic has taught us anything, it is that prevention is better than the cure, and that the WHO forms a crucial element of coordinating and informing that prevention globally. The WHO cannot be seen to be sacrificing its independence or impartiality to commercial determinants of health in order to access greater resources.

The current signs from the WHO Foundation are troubling, and suggest that the spirit and letter of FENSA, developed in recognition of the central importance of managing conflicts of interest, are being sidelined. The reputational risk this could pose for the WHO is considerable, particularly at this crucial juncture, and is at odds with other efforts by the WHO to improve the management of conflicts of interest in global health. The lessons of past failed initiatives can ill afford to be ignored. Global health deserves a far firmer foundation.