IT was the first specialised agency of the United Nations, unanimously willed into being by all nations and inaugurated in April 1948. At the time US President Harry Truman signed up to the new World Health Organization “with the hope and expectation” that it would “help liberate men everywhere from the overhanging dread of preventable disease.”

It was not to be. The latest President has now given notice that the United States is leaving the WHO, which Donald Trump accuses of being “a puppet” of China. “The W.H.O. really blew it. For some reason, funded largely by the United States, yet very China centric” Trump tweeted on April 7. A more accurate claim would be that it is reliant, not just on competing countries and their self interests, but on its billionaire donors, of whom Bill and Melinda Gates are the most prominent.

The funding of the WHO, at more than $5.6 billion over two years, is, like most UN agencies, not straightforward. Nor is it healthy, below even that of many university hospitals and spread, too, across a wealth of public health and research projects. Its income is based on an assessed contributions from countries, judged on wealth per capita, and voluntary donations.

The US is the largest funder, contributing $893 million, or 15% of the budget, whereas China’s share is just $86, or about 0.2%. The second largest contributor is the Gates Foundation, which gave $531m just short of 10% of the entire budget.

Tammam Aloudat, of Médicins Sans Frontières, the global medical charity, observed the “sad truth” that global health is a political field, not a medical one and that countries will act in their own self interest.

The WHO has no authority to sanction or order members to follow its instructions, beyond the vapid provisions of its International Health Regulations. It also lacks the power to order countries to allow access for investigators to trace the outbreak of diseases, crucial in the current Covid pandemic. This weekend, more than six months after the first known outbreak in Wuhan, WHO officials are finally travelling to China to find the source, or not.

The governance of the organisation has also become ponderous and unwieldy. It has an executive board of 34 member-state representatives, but any other country can speak at the meetings, so that decision-making becomes protracted and often descends into factionalism.

It is also criticised for being overly cautious when it comes to scientific evidence, too slow to adapt its guidance to the latest research. The most prominent example is that it took until June 5, six months on in the pandemic, before it made the recommendation that people should wear face masks. It has also been slow to accept that coronavirus can be transmitted by sprays of small particles known as aerosols which can remain in the air for some time.

The WHO has also been slated for the amount it spends on travel expenses, in excess of $200m a year, more than it spends on mental health, HIV/Aids, malaria and TB combined. The previous Director-General, Margaret Chan, was slated for staying in a $1000 a night hotel room while on a visit to west Africa.

The funding model, with around a fifth of the contributions assessed, or essentially mandatory, means that the reliance on the voluntary donors – be they governments, NGOs, foundations or individuals – is enormous. The WHO doesn’t take money directly from drug companies, but it can through the back door. The Vaccine Alliance, GAVI – the fourth biggest donor at $371m – is a public and private body which includes members like the International Federation of Pharmaceutical Wholesalers Foundation, Reckitt Benckiser (the health group), Unilever and Mastercard.

In 2008 Microsoft founder Bill Gates announced that he was stepping away from the company to concentrate on philanthropy, in his words to “leverage all the tools of capitalism” to “connect the promise of philanthropy with the power of private enterprise.” This created a new model of charity where the goal was not to directly help the needy, but help the rich to help the needy, with generous tax breaks.

The US magazine The Nation examined more than19,000 charitable grants the $50bn Gates Foundation has made, among which was almost £2bn in tax-deductible donations to some of the largest companies in the world, including the British pharmaceutical company GlaxoSmithKline.

Linsey McGooey, sociology professor at the University of Essex, is the author of No Such Thing as a Free Gift, which puts the Gates Foundation under the microscope, and examines where social justice increasingly becomes dependent on the questionable generosity of the mega-rich. She asks, for instance, why $19m of the Gates money should go to a Mastercard affiliate aiming at the 2.5bn unbanked people in the developing world, in effect subsidising the commercial business in attracting new customers, but also giving Bill and Melinda a tax break on the donation.

The Gates Foundation has shares and bonds in a spread of companies, like Merck, GlaxoSmithKline and the French pharmaceutical giant Sanofi. The Nation found almost $250m in charitable grants from Gates to companies in which the foundation holds stock. To an outsider it would appear that giving a grant to a company that it partly owns, and stands to benefit from financially, may seem like a conflict of interest, but apparently not.

The Gates Foundation’s $50bn endowment has, over five years, made $28.5 billion through investment, while over the same period giving out $23.5bn in grants. Gates’ own wealth is greater today than it was when he stepped away from Microsoft and into philanthropy, around $100bn, second in the meg-rich stakes only to Amazon’s Jeff Bezos, who is worth $178.4bn, although that will surely have gone up a few digits by the end of this article.

Just as Microsoft’s success was dependent on patents on its software, the Gates Foundation has been a supporter of intellectual property rights for pharmaceutical companies, which critics say makes crucial, lifesaving drugs prohibitively expensive, particularly for developing countries.

Gates has dismissed criticism from health campaigners like Médecins sans Frontières about the high price of drugs, warning that this only serves to deter pharmaceutical companies from working on life-saving products for poor countries and that the threat of bad publicity will deter them from investing in research, although some may think it's probably the shareholders' interests in profits which puts them off.

It also seems to fly in the face of evidence. Last week the US company Moderna – backed by half a billion dollars in government funding – announced that early trials of a Covid-19 vaccine showed an immune response on those treated. Since the vaccine was first announced for human use in February the company’s share price has gone up more than fourfold.

This is a crucial issue given, we are told, that vaccines are just around the corner. How will they be charged and paid for? Some of those, like the Oxford University team partnered by AstraZeneca, say that doses will be free, or at cost, throughout the world, but there’s no guarantee that others will follow.

In the last few days the company said that the Oxford vaccine could be ready as early as October after what appears to be successful mass testing. There are also dozens of other vaccines currently under test.

All of this has put renewed focus on the WHO and whether it is fit for purpose. The director-general Tedros Adhanom Ghebreyesus, known as Tedros, has promised a pandemic inquiry (as has the UK Government, without giving a timescale) and he promised it would examine “whether the global health architecture is fit for purpose”.

Richard Horton, the outspoken editor of the medical journal the Lancet is in no doubt. “Its coordinating authority and capacity are weak. Its ability to direct an international response to a life-threatening epidemic is non-existent.”

Our columns are a platform for writers to express their opinions. They do not necessarily represent the views of The Herald.