Beijing’s History With the World Health Organization

The spread of the COVID-19 pandemic and variations in national responses have revived a fraught debate about the role, mission, and effectiveness of the World Health Organization (WHO). Founded in 1948, the WHO’s original objective was “the attainment by all peoples of the highest possible level of health,” as laid out in its constitution. And yet, while the institution has enacted reforms over its more than 70 years, its handling of the coronavirus raises questions about its ability to manage a truly global health threat and its relationship to powerful member states.

Of late, China is rhetorically pushing for greater international cooperation, notably when it comes to transnational issues, including the coronavirus. But how does this measure up to the state’s actions within the WHO?

Beijing only formally joined the World Health Organization in 1972, after it replaced Taiwan as the “legitimate representative of China” at a slew of institutions that fall under the United Nations umbrella. Over the nearly five decades since Beijing’s integration into the network of multilateral organizations, China’s relationship to global governance, and the public health sector, has evolved significantly over time. This evolution is the result of a confluence of factors, including shifts in the international system, China’s own domestic political and economic reforms, and an evolution in the mission and role of multilateral organizations as they deepen their institutionalization.

The WHO’s initial priorities were working with countries to combat and treat communicable diseases such as malaria and tuberculosis, and later HIV/AIDS. The organization also supports health research and issues guidelines, promoting topics like women and children’s health, nutrition, and sanitation. But as the frequency and volume of international travel increase, the world has been confronted with a growing number of cross-border and global epidemics.

In its role as a technical resource engaging with China, the WHO has been able to alter the country’s internal domestic public health policies. It has made effective use of tools like conditional financing, agenda shifting, reclassifying existing health conditions as problems to be solved, facilitating the establishment of advocacy networks, and acknowledging the positive role that civil society organizations may play in health policy. As an advisory body, the public health entity helped China revamp elements of its own system, to redefine both problems and as well as solutions for noncommunicable and communicable diseases as the country lifted millions out of poverty.

After the fallout of the 2002-2003 SARS outbreak, the WHO’s International Health Regulations were reformed to grant the institution new powers to better respond to health emergencies. Despite its successes in China, and around the world, including significant expansion of health care services in lower-income countries and efforts to eradicate smallpox and polio, the institution is not without its imperfections.

As CFR’s Yanzhong Huang and Thomas Bollyky argue, the COVID-19 pandemic has highlighted that, despite its revisions in 2005, the WHO failed to “prevent the denial and inaction of one nation from putting many other nations at risk of a pandemic of deadly disease.” They add that to remedy the flaws in the existing health system, “we may need a new mechanism to respond to dangerous disease events, a mechanism that has greater independence from affected member states.”

Such criticism is not a new phenomenon. The WHO was similarly challenged on its slow response to the 2015 Ebola outbreak. The frustrations with the system stem from the WHO’s institutional design and authority structure, which favor member state’s decision-making authority and defer to national preferences and agendas.

As the scope of the WHO’s responsibilities and mandate have expanded, so too have its budgetary needs. The organization’s funding is generated from two source types: assessed contributions, which are derived in relation to a member country’s level of economic development and population, and voluntary contributions. Only an estimated 20 percent of the WHO’s budget is made up of assessed funding. Recent budgetary deficits have increased the WHO’s reliance on voluntary contributions, potentially leaving the institution vulnerable to the influence of member countries and organizations that provide sizable contributions overall.

When it comes to Chinese contributions, the overwhelming majority are from its assessed contributions. China’s contributions to the WHO have grown in recent years, reaching approximately $86 million in 2018-2019. Its voluntary contributions also increased slightly, from $8.7 million in 2014 to $10.2 in 2019, though the latter figure only accounted for a small share of its overall WHO contributions. Chinese funds have supported a wide variety of programs, including integrated people-centered health services, outbreak prevention and control, and efforts targeting HIV and hepatitis, among others.

And yet, China’s total contribution still pales in comparison to the U.S. presence in the WHO. The United States is the body’s largest contributor and donor, with a contribution of $893 million for the 2018-2019 period, with more than 73 percent in specified voluntary funding. But the Trump administration, amid the diplomatic spat between Beijing and Washington over the origin of the coronavirus, announced the United States was freezing its contributions to the WHO, accusing the organization of failing to swiftly sound the alarm about the virus. The Trump administration has slammed the WHO for allegedly showing too much deference to Beijing.

Separately, China announced in late spring that as part of its contributions to the international response to COVID-19, it would supplement its funding to the WHO by $50 million.

Chinese pressure on the WHO may not immediately be financial in nature. Instead, it has typically manifested itself vis-a-vis Taiwan’s relationship with the WHO, as well as other multilateral institutions. Although Taiwan was granted observer status to the UN’s public health body from 2008 to 2016 under the leadership of then-Taiwanese President Ma Ying-jeou, Beijing’s brief acceptance of the island’s participation at the annual World Health Assembly under the label “Chinese Taipei” swiftly evaporated with the election of Tsai Ing-wen, whom China sees as a promoter of “Taiwanese independence.”

Some have cast the WHO leadership as complicit collaborators with China as it delayed reports, stalled the entry of an investigation team, and sought to limit transparency on the extent of its domestic COVID-19 outbreak. Others have described the multilateral organ’s actions, including effusive praise of China’s efforts, as “laundering” China’s international image and caving to the pressure and influence of a powerful country.

In many ways, the WHO remains hamstrung by its design, empowered as an agent by member countries while its activities are conducted with the consent of host governments. The organization continues to lack unilateral enforcement powers and inspection rights. Will the United States’ retreat from multilateral leadership all but guarantee a WHO more beholden to China? What the future will hold is likely far less deterministic, though the prospect for further institutional reforms may whither under greater Chinese influence given the country’s strict commitment to the principle of sovereign equality enshrined in the UN’s network of institutions. Still, the history of China’s engagement with the WHO should be viewed as an ongoing and dynamic relationship, rather than through the singular prism of today’s health crisis.