How the 'bureaucratic' World Health Organization ended up on the hot seat over its COVID response

The United States announced this week that it is formally withdrawing from the World Health Organization — ending more than 70 years of participation and cutting off its financial contribution, which is the largest among the agency's members.

The decision comes after weeks of criticism from President Donald Trump for what he called the WHO's inadequate response to the COVID-19 pandemic and its promotion of "disinformation" from China about the virus.

The reaction to the withdrawal has been both swift and sharply divided. Health officials and critics of the U.S. administration labelled it dangerous — with House Speaker Nancy Pelosi describing it as "an act of true senselessness" — while Vice-President Mike Pence, when asked in a Fox News interview on Tuesday whether it was the right time to break with the WHO, responded that it was "absolutely the right time."

"The World Health Organization let the world down.... There have to be consequences to this," he said.

The U.S. decision to withdraw doesn't take effect until July 6, 2021, and could be rescinded under a new administration or if circumstances change.

With so much conflicting information, it can be difficult to discern what is happening behind the scenes. Here, CBC News explains how the WHO really works.

How is the WHO funded?

The WHO began operating in 1948 as a specialized agency of the United Nations, succeeding a number of similar organizations created in response to cholera and other disease outbreaks around the world. To function, it relies on two main sources of funding: assessed and voluntary contributions.

"The WHO is ultimately a membership organization," explained Steven Hoffman, director of the Global Strategy Lab and a global health law professor at York University in Toronto. "It's just that the members are countries."

Instead of paying a pre-determined amount, each member state — of which there are 194 — pays dues according to the size of their economy, or an "assessed" amount. Beyond that, members and individual donors can make voluntary contributions, which currently comprise more than three-quarters of total funding, according to the WHO.

Those funds are often earmarked for particular goals, which, Hoffman said, "can create a lot of inflexibility."

As the organization tries to lead responses to various health threats, it can become difficult to move funds around as consensus changes, "because 80 per cent of its budget is tied up on particular issues that its donors have," he said.

The United States is currently the organization's largest contributor, though it still owes the WHO some $200 million US in current and past dues. As of June, China was behind roughly $30 million, WHO documents indicate.

How does the organization make decisions?

"It's a complicated, bureaucratic monolith," said Raywat Deonandan, an associate professor and epidemiologist at the University of Ottawa.

Deonandan, who has consulted for the WHO in the past, said while the organization engages in education campaigns, research and general guidance, it is especially good at bringing experts together across international boundaries.

That forms a large part of how it has responded to the COVID-19 pandemic — putting together working committees to determine how to approach a scenario and then releasing documents and advisories on how to proceed, he said.

Still, Deonandan said, general criticisms against the WHO have merit. Since it draws scientists and medical professionals from around the world, "they are deeply seeded in the medical paradigm," which can cause them to react slowly to urgent threats, he said.

"There is a distinction between a clinical, medical way of thinking and a public health, population health way of thinking," he said.

In general, the WHO waits for scientific consensus before releasing guidance, which is more typical of clinical practices and can take years to achieve.

"In a public health emergency like the pandemic, you're standing on a train track and a train is barrelling toward you," Deonandan said. "You can't really stop and figure things out at your leisure. You've got to jump off the track right away."

The agency's approach has led to criticism, for example, of waiting too long before declaring COVID-19 a pandemic and slow-to-change recommendations on mask-wearing, and inspired an open letter from hundreds of scientists asking the WHO to address the airborne transmission of COVID-19.

"What we're seeing with the WHO is they're so stuck in that first evidence-based, evidence-threshold paradigm," Deonandan said.

Who has the most influence over the WHO?

With so many different members, private donors and international health issues, determining the biggest influence on the organization is a difficult thing. Formally, the World Health Organization is guided by the director general — currently Tedros Adhanom Ghebreyesus — who is elected by the member states to a five-year term.

Over the course of the COVID-19 pandemic, both he and the organization at large have drawn sharp criticism for purportedly taking too much direction from China, where the disease was first identified.

Ghebreyesus announced on Thursday that the WHO will set up an independent panel to review its handling of the pandemic. He also said the review is not linked to the withdrawal decision by the U.S. 

But there is a widespread belief that China holds a disproportionate influence over the WHO at the moment, Deonandan said. At the same time, he noted, the U.S. has displayed considerable influence over the agency due to its financial contributions.

Hoffman also pointed to the U.S. as the country with the most direct influence over the WHO's actions.

"It is a little surprising that the United States has been saying that China has been asserting undue influence over the organization," Hoffman said, "when most commentators have expressed that same concern with respect to the United States."

Despite policies being driven by wealthier nations, the decision on what issues to respond to is most often set by low-income countries, where resources are most critically needed, Deonandan said. 

"To say that they are the puppets of the Americans, or the puppets to the Chinese — it's not really how it works."

How is it held accountable?

The WHO is primarily held accountable by its member states. The organization monitors itself through its governing bodies, such as the World Health Assembly, the Executive Board and regional committees. 

It is standard practice for the World Health Assembly to conduct a post-pandemic review of "whether things went right," such as the one recently announced, Hoffman said. In the end, though, it is still fundamentally up to the member states to act if they feel the organization is failing in its mandate. 

"Ultimately, of course, the cheque stops with who writes the cheques," Deonandan said. "So member states, you always have the opportunity, as Americans are now showing, to stop writing cheques."