How U.S. Policy is Rewriting Global Health [Guest Essay]
Newsletter Edition #282 [The Files In-Depth]
Hi,
A common refrain these past few months has been “What happens in the U.S., does not stay in the U.S.”
With every passing week, the foreign and economic policy pursued by the Trump administration, continues to have enormous impact on global health, as it has especially been since the beginning of 2025.
In today’s edition, our guest contributor, Jirair Ratevosian from the Center for Strategic and International Studies (CSIS), analyses recent developments in American policy that cuts deep into health systems worldwide. Among his other roles, Ratevosian was a policy advisor on COVID-19 and global health under the Biden administration. (You can follow him on Substack here.)
We hope you find this edition helpful in understanding how domestic U.S. policy on health and spending have implications elsewhere.
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Priti Patnaik
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I. GUEST ESSAY
How U.S. Policy Is Rewriting Global Health
By Jirair Ratevosian
Ratevosian is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C., and is a Hock Fellow at the Duke Global Health Institute.
The Trump administration has launched a sweeping overhaul of U.S. foreign assistance, with global health as a primary target. In May 2025, it submitted a rescission package proposing billions in cuts—mostly concentrated in global health and development aid. This follows an earlier freeze on foreign assistance, the elimination of USAID as a standalone agency, and a rapid consolidation of U.S. global health efforts under the State Department. The FY 2026 budget proposal cements this trajectory, seeking to slash global health accounts by over $6 billion and eliminate the Global Health Center at the U.S. Centers for Disease Control and Prevention (CDC) .
Within global health, the President’s Emergency Plan for AIDS Relief (PEPFAR)—the U.S.’s flagship HIV/AIDS program—faces a proposed 25% cut. While PEPFAR would remain the largest portion of the global health account, other essential bilateral programs—targeting tuberculosis, malaria, and maternal and child health—are also slated for reductions. These programs are being merged into a newly centralized Bureau of Global Health Security and Diplomacy within the State Department, fundamentally altering their mission from development-focused to diplomacy-driven.
Multilateral institutions are also under threat from US budget actions. The proposed budget includes no funding for Gavi, the Vaccine Alliance—effectively ending U.S. contributions to childhood immunizations in low-income countries. (See NYT: Kennedy Withdraws U.S. Funding Pledge to International Vaccine Agency. Watch his remarks here.)
It attaches strict political conditions to U.S. support for the Global Fund and proposes pulling all U.S. funding from the World Health Organization (WHO), along with a majority of other UN and multilateral agencies. These moves further signal a retreat from multilateralism at a time when international cooperation on health is most essential.
This restructuring echoes trends in other donor countries. The United Kingdom, for instance, integrated DFID into the Foreign Office in 2020, citing coherence and cost-efficiency. Norway and Australia have made similar moves in the past. But the U.S. shift differs in its abruptness and scale, bypassing meaningful stakeholder engagement and risking disruption to programs that rely on predictable, sustained investment. The development community—both in Washington and globally—has raised alarm over the potential breakdown of long-standing health partnerships.
For European audiences, it’s worth noting that while U.S. global health assistance is being dramatically reduced, what's left is still substantial—and far exceeds the contributions of most donor countries. In 2024, the U.S. contributed roughly $11 billion to global health, nearly half of all donor funding. That leadership, however, is now in question—and Europe may be forced to reassess how much it can rely on Washington as a partner in global health equity.
These shifts are triggering long-overdue conversations about the structure and purpose of global health. A reckoning is underway—driven not just by political headwinds in the U.S., but by the inherent flaws of a system that has long been fragmented, overly complex, and poorly coordinated.
Major restructuring efforts are already in motion at WHO and UNAIDS, as both institutions grapple with evolving mandates and constrained resources. Within U.S.-backed programs, including PEPFAR, a number of reforms—advanced by myself and colleagues—are focused on supporting aggressive but predictable and respectful country transitions, leveraging innovation, and improving accountability.
Now is the time for U.S. Congress to support PEPFAR in undertaking careful and strategic multi-year transition plans—ones that responsibly graduate countries onto long-term, nationally led sustainability pathways. These efforts must be coordinated with governments, multilaterals, community stakeholders, and the private sector. At the same time, PEPFAR should adopt a more agile posture, leveraging innovations such as long-acting PrEP and AI-powered digital health tools to scale prevention and strengthen programming. Beyond 2030, PEPFAR should continue playing a critical role in disease detection, technical assistance, capacity sharing, and other efforts essential to sustaining effective and resilient HIV responses.
(See CSIS: PEPFAR’s Golden Era Is Over. It Urgently Needs a Five-Year Transition Plan)
In the vacuum left by public donors, philanthropic foundations and private sector actors are being looked to not just as financiers—but as agenda-setters in global health. Institutions like the Wellcome Trust and the Novo Nordisk Foundation now wield outsized influence, with multi-billion-dollar endowments and growing ambitions in areas such as antimicrobial resistance, metabolic disease, and epidemic preparedness.
At the same time, tech-aligned philanthropies and corporate social responsibility arms—from the Gates Foundation to pharmaceutical and data companies—are shaping delivery models, funding priorities, and even governance structures. While this influx of private capital brings flexibility and innovation, it also raises concerns around transparency, public accountability, and the representation of low-income countries and civil society in decision-making.
Still, there is opportunity amidst the upheaval. This moment of disruption can be a turning point—an opening to reform and reorient donor efforts around country-led, community-driven priorities. Rather than propping up parallel systems, bilateral assistance should align with national plans, strengthen local institutions, and invest in integrated delivery models that reflect how people actually seek care. The future of global health demands a fundamental shift in how power, voice, and trust are distributed across the system. What countries are asking for—predictability, partnership, and integration—must become the organizing principles of a new global compact. In that vision, global health is not something done to countries, but with them.
That’s why my colleagues Mumbi Chola and Judith Auerbach are launching the Kigali Call to Action ahead of the International AIDS Conference in Rwanda this July. We are asking world leaders to commit to a new era of cooperation—one that centers national leadership, community wisdom, and equitable financing.
The future of global health won’t be paused for Washington. It will be built by those willing to lead with urgency and purpose.
Contact author: jirair.ratevosian@duke.edu
Also see:
Amended Senate Budget Bill Would Trigger Nearly 20 Million People Losing Health Insurance
US Senate holds marathon vote on Trump's 'big beautiful bill'
II. PODCAST CORNER
Dialogues: a conversation with Joanne Liu
In this episode of Dialogues, host Garry Aslanyan speaks with Joanne Liu, a Canadian pediatric emergency doctor and former International President of Médecins Sans Frontières (MSF). She is currently a professor at McGill University School of Population and Global Health, where she leads research on pandemic preparedness and emergency response. In this conversation, she speaks about her new book, "Ebola, Bombs, and Migrants." It's a powerful reflection on her leadership journey, and what it really means to demonstrate global solidarity for those most vulnerable.
Listen here
Garry Aslanyan is the host and moderator of the Global Health Matters podcast. You can contact him at: aslanyang@who.int
This podcast promotion is sponsored by the Global Health Matters podcast.
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