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t’s anyone’s guess which of the three candidates still in the race to become the next director-general of the World Health Organization will emerge victorious when WHO’s 194 member states vote in May.

But ask anyone what the next director-general’s biggest challenge will be and you’ll hear the same answer — especially from the woman the candidates are vying to succeed.

“My successor needs to continue to address the financing of WHO,” Dr. Margaret Chan, who recently passed the 10-year mark in office, told STAT in an interview. “There’s no two ways about it.”

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The global health agency Chan has led since Jan. 4, 2007 is perennially strapped for cash. Its guaranteed funding — the dues paid by member states, which make up only 20 percent of the annual budget and can be spent at the agency’s discretion — has been frozen for more than a decade.

But there’s reason to think that the WHO’s financial situation could soon become more dire. While 80 percent of the agency’s budget has come from a dozen or so countries and donors in the past, that money comes with taut strings attached. If the world manages to reach a long-sought goal — eradicating polio — a big chunk of the voluntary contributions WHO receives could disappear.

There may also be politics at work. A rise in nationalist sentiment in much of the world, including in the United States, is raising questions about global commitment to multilateral agencies like the WHO.

Given the agency’s fiscal challenges, Chan has served notice she will ask for a 10 percent increase in members dues — assessed contributions in the vernacular of United Nations agencies — at the WHO’s annual meeting, the World Health Assembly, in May. Her request may not be granted.

She sought an increase when the WHO’s 2016-2017 budget was set — at a time when the agency’s Ebola response was being critiqued and roundly slammed — and was rebuffed. A meeting last October to discuss the issue indicated some but not overwhelming support for her upcoming request.

Some observers suggest a funding increase would represent both a clean slate and a mandate for the agency’s next leader.

“There’s not going to be a better time to do this than at the change of leadership,” said Dr. Jeremy Farrar, director of Britain’s Wellcome Trust charity. “They can say, ‘Look, this job is possible if you give the following resources.’”

Others, such as Dr. Ashish Jha, director of the Harvard Global Health Institute, think the WHO has to prove that it has fixed its problems before countries will agree to pony up more cash.

Jha, who was an author of an Ebola post-mortem that was critical of the WHO, acknowledged the agency is caught in a vicious cycle. Underfunding has undermined the WHO’s ability to do its job; its failings make member states less inclined to contribute more.

“It’s really hard to get member states to be the ones that are going to break this cycle. In fact, I think WHO needs to break this cycle,” Jha said.

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Chan has moved to increase transparency of how the WHO spends its money, and to reduce spending — by holding more online meetings rather than flying experts to Geneva from around the world, for example. She’s also moved some of the agency’s work to lower-cost locales, such as Malaysia and Hungary.

And Chan has demanded countries account for how they spend direct aid from the WHO. It was always a requirement, but recipients were often lax about complying. She put her foot down.

“Two years ago I gave the warning, in a nice way. Diplomatic way. If you do not help me to have timely reporting to my donors I’m going to stop direct financial cooperation,” she said.

Jha isn’t wowed by the reform effort undertaken to date. “I think it’s pretty modest. And in my mind, it’s not enough.”

The WHO has an annual budget of $2.2 billion, about half that of Harvard University, or 7 percent of the budget of the National Institutes of Health. For 2017, the United States will pay $113.5 million in dues.

The WHO draws up recommendations for things like salt and sugar consumption, leads tobacco control efforts, promotes road safety, fosters the strengthening of health systems, monitors for and responds to outbreaks of dangerous infections diseases, and myriad other responsibilities.

Wealthy countries have the public health manpower to devise their own guidelines for doctors on how to treat, for example, gonorrhea — which is mowing its way through the last antibiotics available to cure the infection. But many countries rely on the WHO’s guidance for issues like this.

Yet most of the budget approved by member states is not actually money in the bank. With the exception of the assessed contributions — that 20 percent — most of the budget is really no more than an aspiration. In effect, it is a green light for the agency to spend up to the budgeted amount — if it can raise the cash.

“In a nutshell, the complexity of financing for WHO is the biggest problem that hampers UN agencies including WHO to do and focus on what they’re good at. You can ask my staff — any of them,” Chan said. “They spend a big proportion of their time writing [grant] proposals, getting money in.”

A looming development could make the agency’s funding problems even worse. Currently about $1 out of every $4 the WHO brings in is earmarked for the polio eradication program. That program, launched nearly three decades ago, appears to be nearing its goal.

Last year, there were 37 cases of polio across the globe, a record low; this year there have been none to date. The hope is that transmission of virus will cease this year, starting the clock on a three-year countdown to a declaration that polio is history. (The poliovirus is the ultimate whack-a-mole, so don’t count it out just yet.)

If the finish line is crossed, there will need to be surveillance for some time to ensure the threat is really gone. But the armies of polio workers — some of whom are also involved in the delivery of other services, such as routine childhood immunization programs — will no longer be needed. Money on which other programs have piggybacked may well melt away.

“It’s a big deal,” Chan said of the prospect of the loss of the polio money, noting the WHO would be on the hook for $50 million in payouts if it has to let the polio workers go. A more productive use of money would be to reallocate that workforce to other programs, she said.

“If donors walk away from polio without repurposing their contributions to health systems, that’s a big problem. But we need to give them ammunition and advance notice so that they know they can reprogram the polio money to EPI” — the expanded program on immunization — “or to health systems. That’s the journey we have to take,” Chan said.

It remains to be seen if countries will agree to increase their WHO dues or to maintain voluntary funding at current levels once the polio job is done.

Jha said the agency must do more to prove itself to funders. “I think of the assessed contributions versus voluntary contributions [debate] as a symptom of the problem and not a cause of the problem.”

To bolster his point, Jha noted that a new initiative to foster development of vaccines for diseases that pose pandemic threats — the Coalition for Epidemic Preparedness Innovations or CEPI — managed to raise $460 million in a single year. “Wow, that’s a pretty sharp contrast,” he said.

But Farrar insisted countries should arm the WHO to be the effective global health agency the world needs, especially in these times of rising populism and protectionism.

“These are absolutely critical times for … the whole global architecture for transnational partnerships and coordination,” he said. “All of these things are under current challenge by countries who are seemingly retreating into a more national agenda.”

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