WASHINGTON - US President Donald Trump's threat last week to permanently pull America's funding of the World Health Organisation (WHO) shone the spotlight on how much the global health agency depends on its member states for funding.

But his accusations that the WHO was too close to China also laid bare the organisation's near-total reliance on member states for information and the mandate to act.

The problem, say public health and international relations experts, lies in how the WHO is structured and designed not to be independent.

"The WHO we have today is the WHO that the world has chosen to build," said Council on Foreign Relations global health programme director Thomas Bollyky and Centre for Global Development senior policy fellow Jeremy Konyndyk in a Washington Post commentary last month.

"The tendency of WHO to defer to its member governments in a crisis should absolutely be reviewed after the current pandemic ends. Yet it also should be recognised that deference flows from constraints that WHO member governments, including the United States, have chosen to impose upon it," they added.

Funding with strings attached

Founded in 1948 after World War II, the WHO is headquartered in Geneva with six regional offices and 150 country offices.

Its 194 member states pay mandatory membership fees that are calculated based on their population and wealth, known as assessed contributions.

But these contributions make up less than 20 per cent of the WHO's funding. The rest comes from voluntary contributions from governments paying above and beyond their dues, and donations from philanthropic foundations and other groups, which are often earmarked for specific purposes.

The WHO's budget for its latest two-year cycle was US$5.62 billion (S$8 billion), of which 77 per cent, or US$4.3 billion, was in specified voluntary contributions.

America was the top contributor, its funds making up 15.9 per cent of the WHO's latest budget. The Bill and Melinda Gates Foundation came in second at 9.4 per cent, and Britain third at 7.7 per cent. Gavi, the Vaccine Alliance, was number four at 6.6 per cent, while Germany came in fifth at 5.2 per cent.

"Over the past decade, the WHO has become increasingly dependent on voluntary contributions, which puts pressure on the organisation to align its goals with those of its donors," said the Council on Foreign Relations, a Washington-based think tank, on its website.

That also leaves the WHO vulnerable to threats from top donors, as seen in 2018 when the US reportedly threatened to cut its contributions to the WHO if other countries went ahead with a resolution to encourage breastfeeding, which went against the interests of infant formula manufacturers. The New York Times reported that the US ultimately stopped opposing the resolution after Russia introduced it.

CFR senior fellow for global health Huang Yanzhong blamed this vulnerability on member states, which help shape the WHO's priorities and resources and the secretariat's mandate, for not giving the WHO secretariat the necessary authority and resources to push reforms.

He noted that in May 2015, member states rejected then WHO chief Margaret Chan's proposal to increase assessed contributions by 5 per cent.

The increase would have ensured that the organisation's budget was fully funded, giving it more funds for quickly responding to emergencies - something it lacked during the Ebola outbreak of 2014.

Overly deferential

Health experts note that some of the WHO's failures in its handling of the coronavirus pandemic were familiar, seen also during the 2014 Ebola outbreak.

The WHO was then widely panned for being slow to declare the Ebola outbreak a public health emergency of international concern.

Reasons for the delay included concerns that declaring the emergency might anger the African countries involved and hurt their economies, according to leaked e-mails reported by the Associated Press.

In the case of the coronavirus, the WHO has come under fire for parroting information from China later found to be false. For instance, it said on Twitter on Jan 14 that preliminary investigations by Chinese authorities had found no clear evidence of human-to-human transmission of Covid-19 in Wuhan.

But the WHO has no power to send in independent fact-finding teams into member states without their permission. This makes them reliant on member countries for information, and encourages them to play nice to coax information out of them.

Said global health law professor Lawrence Gostin and global health assistant professor Matthew Kavanagh, both of Georgetown University: "We would have preferred to hear more about China's muzzling of independent scientists, lack of transparency and human rights violations.

"But WHO leaders have long walked a fine line to keep communication open while coaxing international cooperation. US personnel got key early epidemiological data from China only because the WHO brokered access," they wrote in a Washington Post commentary last month.

Nonetheless, experts note that the WHO has been less afraid to step on toes in the past, having publicly pointed out gaps in vital data from China during the Sars crisis of 2003.

But what the WHO needs now is not defunding - as the US has threatened - but reform in the aftermath of the coronavirus pandemic, like those done after the Ebola crisis, said experts.

Said Dr Gostin of the WHO on Twitter: "Without them we would be much less safe. We shouldn't attack and demoralise, but fund and strengthen."