Global health. The current scenario and future perspectives

34 As can be seen, the process of effectively incorporating new and multiple actors into the international system is still under construction. Financial resources Like all UN agencies, the WHO’s budgetary mechanism revolves around the debate and approval of a biennial program-budget by the World Health Assembly. Although each country’s contribution or quota is determined according to a formula that includes GNP, population and other factors, making for a variety of amounts, each country has the same formal political weight (vote) when it comes to decision-making. The sum of the quotas is known as the regular budget and is at the free disposal of the Secretariat. According to the formula, the US should pay about one-third of the budget. However, in the 1980s, the US announced that its maximum contribution to multinational entities would be limited to 25% of the total budget. In addition to this arrangement and given the constant pressures for reforming the institution and the new demands of global health, the World Health Assembly decided not to increase the real value of the regular budget (adjusted for inflation). Subsequently, the real budget was limited to its nominal value, which means it was reduced by inflation. Since its inception, the WHO has accepted extrabudgetary funds (EBF) for specific tasks requested by some member countries (vaccines, specific diseases, etc.). The freezing of the regular budget and the increasing demand for services have led to a growing dependence on voluntary contributions, initially limited to member states and later including other international agencies, as well as some foundations from the private sector. These EBF considerably exceed the regular budget. For the biennium 2018- 19, the WHO’s budget was USD 6.017 billion, of which only 16% came from regular funds and 84% from EBF. For the biennium 2020-21, EBF accounted for 88% of the total, which likely reflects the urgency posed by the Covid-19 pandemic, compared to 80% in 2016. According to the WHO’s definitions, member countries are the main source of EBF (55%), followed by multinational agencies, including International Financial Institutions, with 16%, and then foundations like the ones mentioned before (14%). The for-profit private sector contributes 1%. During the biennium 2018-19, the main contributors to the WHO were the US, the UK, the Gates Foundation, GAVI and Germany. Non-state entities only contribute to EBF, but it is worth noting that the EBF from major contributing member states is several multiples of their regular funds, except for the US, where both flows are similar. The contribution made by