Trump's Snub to Global Health Leaves The Field Wide Open
Newsletter Edition #247 [The Files In-Depth]
Hi,
Global health is not a zero-sum game, but political expediency demands simplistic narratives, whether it is contributions to global health financing or how outbreaks emerge.
In today’s edition, we examine the various implications of the U.S. withdrawal from World Health Organization. While it will take weeks and months to fully understand the impact of such a decision, the consequences will be enormous. (While there is plenty of theorizing around the implications, the very real impact on sexual minorities, women and children, among other issues, is not an abstraction.)
We spoke to a range of experts, policymakers, diplomats for this story.
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I. ANALYSIS
Trump’s Snub to Global Health Leaves The Field Wide Open
The decision of President Donald Trump ordering the U.S. exit out of World Health Organization, has not just made financing pressures more acute for the UN’s only technical agency, it has also upended American, and as a consequence, global health policy-making. This will potentially unleash vast, and possibly irreversible changes in the overall governance of the field.
It is a legitimate question to ask if so much depends on just one WHO member state. The answer to this is both yes and no.
The U.S. and its government agencies, are the biggest contributors to WHO.
According to WHO, the share of US funding of about US$706 million in the WHO financing, represents 10% of the approved budget for 2024-2025 of US$ 6.8 billion and 18% of the total revenue at the end of December 2024 (US$ 3.9 billion).
The U.S. is the biggest donor to the institution taking into account both voluntary contributions and membership fees. (The financial period for WHO’s programme budget is two consecutive calendar years)
So, when the U.S., pulls the plug on financing as ordered by President Donald Trump, hours after he assumed office earlier this week on January 20, 2025, the consequences for WHO are near immediate. However, this is not entirely clear given current contractual arrangements, and potential legal challenges to such a decision. (We discuss this more in detail below)
Apart from the financing issues, the overall direction of the Trump presidency will have lasting and deep impacts on global health, whether it is addressing health emergencies, or sexual and reproductive health, or even on matters of race – the bedrock of inequities in many countries including the U.S. While there are financial implications for these disciplines within global health, the ripple effect of such policies on these issues could spread and far, and win willing allies across the Atlantic, and in many other parts of the world.
It will be no exaggeration to say that this has a seismic effect on the field. (This has not been out of the blue. There were indications that President Trump would take such a measure given his previous decision in 2020.)
Scholars have questioned and contested, the outsized influence of American policy on global health. But given the deep influence and investments by the U.S. over decades, the field has been decisively forged, governed and shaped by American interests. Senior diplomats from developing countries have often described this as “insidious”.
All of that could potentially change, if other countries (193 member states of WHO, apart from the U.S.) decide to step up, not only in terms of plugging the hole in financing for an organization that is already struggling, but if they articulate clear visions and interest on how they want WHO and global health to be shaped. That looks like a distant possibility though. Inward looking politics, a retreat from internationalism, tariffs wars and cosy bilateralism, will dominate political calculations, that could leave multilateralism floundering.
Given that Europe is grappling with myriad geopolitical challenges and domestic pressures, the field is wide open for other players, including non-state actors to step in. If COVID-19 was any marker, changes in global health governance will move swiftly.
Experts say there appears to be no appetite, or leadership among member states, to rescue WHO, because of political and financial frailties. A leadership vacuum, therefore provides carte blanche for interested parties. After all, multistakerholderism is a reality for much of the United Nations, and for countries.
(Also, see one of the actions in Trump’s order: “identify credible and transparent United States and international partners to assume necessary activities previously undertaken by the WHO.”)
Apart from implications for the U.S., this could really be an irreversible moment for WHO and for global health. This is the most likely scenario, experts say: exit American government, and enter American philanthropists. If this crisis is perceived as posing near-existential risks for WHO, all gates will be opened to accept funding from private sources. And we well know, that once such a transition occurs, it will become a part of the firmament in global health.
In this comprehensive story, we examine the U.S. Presidential orders that affect global health, and how experts see these issues evolving. We look at the impact on WHO financing; on recent and on-going negotiations for Prevention, Preparedness And Response during health emergencies; and the wider impact on global health.
THE TRUMP EFFECT ON THE FINANCING OF WHO
The Executive Order Withdrawing The United States From The World Health Organization, goes back to the 2020 decision and instructs the following, among other intended actions: a pause of future transfer of funds to WHO; overhauling U.S. global health security strategy; ceasing participation from on-going negotiations on Pandemic Preparedness Prevention And Response.
The order says:
“(a) The United States intends to withdraw from the WHO. The Presidential Letter to the Secretary-General of the United Nations signed on January 20, 2021, that retracted the United States’ July 6, 2020, notification of withdrawal is revoked.
(b) Executive Order 13987 of January 25, 2021 (Organizing and Mobilizing the United States Government to Provide a Unified and Effective Response to Combat COVID–19 and to Provide United States Leadership on Global Health and Security), is revoked….”
The reasoning is described as follows:
“Section 1. Purpose. The United States noticed its withdrawal from the World Health Organization (WHO) in 2020 due to the organization’s mishandling of the COVID-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states. In addition, the WHO continues to demand unfairly onerous payments from the United States, far out of proportion with other countries’ assessed payments. China, with a population of 1.4 billion, has 300 percent of the population of the United States, yet contributes nearly 90 percent less to the WHO.”
The above reasoning has prevailed since the onset of COVID-19 in the unfortunate early months of 2020 when WHO was perceived as being unable to persuade China to share information on the origins of SARS-CoV-2.
The casting of China as an adversary in American politics and narratives, goes beyond global health (think trade), and holds true across the U.S. political spectrum. But specifically, viewing Assessed Contributions (membership dues to WHO) solely in terms of population does not accurately capture the complexities of global health financing and the role of aid.
UNPACKING WHO PAYS HOW MUCH
According to WHO, “The assessment scale is calculated by the United Nations based mainly on the country’s GDP and is adjusted for WHO’s membership.”
The UN scale of assessment is determined by a formula that seeks to arrive at a country’s “capacity to pay.” The formula is a function of a country’s share of global gross national income, and also takes into account factors such as debt and population. Based on this, the U.S. accounts for 22% in the current period. (See how all WHO member states stack up on membership fees to the organization).
According to WHO, the US contribution for the 2024-2025 biennium is a total of US$ 706 million: US$ 264 million in assessed contributions and US$ 442 million in voluntary contributions (16% of total Voluntary Contributions).
The membership fees for 2024 due to the U.S., has not yet been received by the organization, sources confirmed to us.
LEGAL IMPLICATIONS OF THE ORDER
So, while the failure to pay dues could result in the suspension of voting rights, as per Article 7 of WHO’s Constitution, this will not have the intended impact because of Trump administration’s stated decision to withdraw from the institution.
Lawrence O. Gostin, a renowned global health legal scholar at Georgetown University in Washington D.C. told us: “I have never known Donald Trump to be a respecter of law, rules and obligations. By law, he is supposed to give one year's notice of the intention to withdraw from WHO and to pay all financial obligations. But he basically said that he went back to his 2020 decision to withdraw, and that the time period is up - and we are now withdrawing. So, he hasn't even given the one-year notice.”
(On 7 July 2020, the US Secretary of State notified the UN Secretary-General, in his capacity as depositary of the WHO Constitution, that the US Government was withdrawing from WHO, effective 6 July 2021.)
Sources familiar with the current dynamics in Geneva, told us:
“In accordance with the US reservation to the WHO Constitution accepted by the World Health Assembly in 1948, the US is the only WHO Member State that has an express right to withdraw from the Organization. Any such US withdrawal would according to a provision of US law be subject to two conditions: a one-year notice; and the US meeting in full its financial obligations to the WHO “for the organization’s current fiscal year.”
In what is exceptional, sources told us that the U.S. is the only WHO Member State having ratified the Constitution with such a reservation.
Some of the intended actions in the Trump order say:
“…(c) The Assistant to the President for National Security Affairs shall establish directorates and coordinating mechanisms within the National Security Council apparatus as he deems necessary and appropriate to safeguard public health and fortify biosecurity.
(d) The Secretary of State and the Director of the Office of Management and Budget shall take appropriate measures, with all practicable speed, to:
(i) pause the future transfer of any United States Government funds, support, or resources to the WHO;
(ii) recall and reassign United States Government personnel or contractors working in any capacity with the WHO; and
(iii) identify credible and transparent United States and international partners to assume necessary activities previously undertaken by the WHO.”
HOW CRITICAL IS AMERICAN MONEY FOR WHO?
The short answer to this question is “very”. The philosophical answer is “it depends”.
The impact of this decision by the U.S., will be near-calamitous if the funding gap is not plugged in sufficiently and swiftly.
In the current biennium 2024-2025, the size of WHO’s base budget is US$4.9 billion over two years. (According to WHO, base budget is the largest component and the scope is set by WHO, covering and work done across all three strategic priorities [Universal Health Coverage, Health emergencies, Healthier populations]. This also includes enabling functions for by country offices, regional office and headquarters.)
Note that the overall Programme Budget is bigger (US$ 6.83 billion), that also takes into account special programmes, The Global Polio Eradication Initiative (GPEI) and Emergency operations and appeals, apart from the base budget. Typically, for the purposes of understanding WHO’s strategic and operational needs, the base budget is what is considered.
The U.S. voluntary specified contributions (US$ 442 million during 2024-2025 account for 16% of total VCs), go into a range of areas earmarked by the administration in contractual arrangements with the WHO. (See an interactive chart on financial flows here.)
According to WHO, these specified funds are disbursed through headquarters and country offices towards outcomes including: improved access to quality essential health services irrespective of gender, age or disability (25.35%), acute health emergencies rapidly responded to, leveraging relevant national and international capacities (23.04%); Polio eradication and transition plans implemented in partnership with the Global Polio Eradication Initiative (18.43%); Epidemics and pandemics prevented (11.97%); Health emergencies rapidly detected and responded to (7.62%); Countries prepared for health emergencies (5.43%), Strengthened country capacity in data and innovation (2.1%); Improved access to essential medicines, vaccines, diagnostics and devices for primary health care (1.66%), among many others areas.
The areas most dependent on U.S. voluntary funds include Emergencies, Polio, Preparedness, Readiness-Prevention, Core Response, HIV, Hepatitis, TB, Immunization and Malaria, sources indicated.
Even before the Trump announcement, WHO’s finances have been shaky. See below a heat map that show under-funded areas in its mandate.
To understand, the impact of chronic financial stress in the organization, see a revealing report from the WHO Ombudsperson that describes in detail staff morale and dynamics as a result of unpredictable financing. This report will be considered by the WHO Executive Board early next month in February 2025.
In order to reduce dependence on fickle donors, WHO member states have worked on ways to improve financing conditions for the institution, including by negotiating an increase assessed contributions, structuring an investment round, and reforming overall budgetary and governance processes. These reforms are underway and have met with modest success. This latest setback for WHO will exacerbate existing challenges.
To fund its next strategy 2025-2028, WHO needs US$ 7.1 billion. As on the end of 2024, it was able to secure US$ 3.8 billion for the next four years on the back of pledges from some of its member states, the private sector, foundations and multilateral organizations. WHO had said it has successfully increased predictability as compared to 2020, when WHO had visibility for only 17% of funding required for its previous strategy.
However, if new funders that come in set conditionalities, the goals having unearmarked funding may not be met.
STATEMENT FROM WHO ON THE U.S. DECISION
Following the Trump decision, WHO stated:
“The World Health Organization regrets the announcement that the United States of America intends to withdraw from the Organization.
WHO plays a crucial role in protecting the health and security of the world’s people, including Americans, by addressing the root causes of disease, building stronger health systems, and detecting, preventing and responding to health emergencies, including disease outbreaks, often in dangerous places where others cannot go.
The United States was a founding member of WHO in 1948 and has participated in shaping and governing WHO’s work ever since, alongside 193 other Member States, including through its active participation in the World Health Assembly and Executive Board. For over seven decades, WHO and the USA have saved countless lives and protected Americans and all people from health threats. Together, we ended smallpox, and together we have brought polio to the brink of eradication. American institutions have contributed to and benefited from membership in WHO.
With the participation of the United States and other Member States, WHO has over the past 7 years implemented the largest set of reforms in its history, to transform our accountability, cost-effectiveness, and impact in countries. This work continues.
We hope the United States will reconsider and we look forward to engaging in constructive dialogue to maintain the partnership between the USA and WHO, for the benefit of the health and well-being of millions of people around the globe.”
Few expect the Trump administration to reconsider its decision.
SO, WHAT’S PLAN B TO PLUG THE HOLE?
Some experts are of the view that WHO will have to make serious efforts on prioritizing its goals and managing its risks. Previous discussions and efforts to prioritize its activities have not been successful since these choices are also political, and less straight-forward given the diversity in member state capacities.
According to a document that will be presented to the EB next month, “The WHO Global Risk Management Committee has prioritized the following principal risks for the biennium 2026–2027: unsustainable financing; simultaneous grade 3 emergencies; abuse of power and harassment; fraud and corruption; sexual misconduct and harassment not prevented or addressed; cybersecurity breach; inability to demonstrate results and impact; strained workforce mental health and well-being; mistrust in science and WHO and Business Management System transition.”
If WHO member states do not want to prioritize and restructure WHO’s mandate, they will have to pay more to support it. And if they do not, and cannot pay more, someone else will have to foot the bill. And we know that several actors with deep pockets will be willing to do more, albeit with conditions.
Andrew Harmer, from the Queen Mary University of London, said:
“I’m more optimistic than some that other member states will increase their Voluntary Contributions – they may interpret US withdrawal from multilateral institutions as weakness, and see an opportunity to increase through these institutions, their geopolitical influence. It just needs one or two leaders from BRICS or Gulf States to be bold and commit to WHO, and others might follow, putting the US on the back foot. That’s my hope.
For too long, the US has manipulated, influenced, and distorted WHO policy; it has often been the voice of criticism at WHA, moaning about x or y and complaining about the amount of money it gives to WHO; and it has been quick to criticise and pressure the Secretariat and do the Organisation down. Unlike most of the other 194 Member States of WHO – who genuinely value the Organisation and what it does – the US has always been a reluctant member. Maybe a spell away might help it to get a sense of perspective?”
Other experts suggested this week, “…The newly expanded BRICS nations have a poor track record in funding multilateral organisations. Still, many have the capacity to significantly increase funding, especially with non-earmarked grants to WHO, including Brazil, China, India, and South Africa. The Gulf States have enormous financial capacities and should step up to support WHO, especially given their interest in addressing the health challenges in the Middle East. Their investments would demonstrate a shared commitment to global health security. Beyond increased funding, governments can directly support WHO by seconding public health experts to the organisation. This would offset potential staffing shortages while ensuring continued technical collaboration between WHO and its member states.”
But not all agree that other WHO member states will step up.
Sources familiar with the behind-the-scenes activity indicate that at this stage there is little chance that any of the other countries will step up significantly. There are suggestions, that some philanthropists may play a greater role. Any such funding will come with conditions attached, a health financing expert said.
THE SPECIFICITY OF WHO
Experts also believe that it is WHO, in particular, has been in Trump’s firing line, compared to even other UN agencies, or other global health agencies. “It is not that U.S. administration has a similar outlook on all health or other UN organizations. If they feel that an institution can secure their interests, they would support it,” the expert added.
And therefore, Gavi – The Vaccine Alliance, and The Global Fund to Fight AIDS, Malaria and TB – both American creations, will be relatively safer than WHO, the expert was of the view.
“These big health agencies have worked hard on Capitol Hill over the years. It will pay off now. WHO does not have that kind of an outreach,” the expert added.
Leaving the WHO will come at a cost. Sources explained that the U.S. will not be a part of these processes after the exit: will not be able to attend World Health Assembly; not be eligible to join the EB and its sub-committees; not be a part of intergovernmental negotiating bodies or the Regional Committee for the Western Pacific or the International Agency for Research on Cancer (IARC); not be a part of the Pandemic Influenza Preparedness (PIP) Framework and the Member State mechanism (MSM) on Substandard and Falsified Medical Products. The Pan-American Health Organization PAHO is a separate IO, but also serves as WHO Regional Office of the Americas.
Geneva-based sources also told us that WHO traditionally has had strong links with the U.S. CDC and USAID. “The mandates of both of these U.S. agencies will be difficult to achieve without a strong partnership,” a source explained to us this week.
AMERICAN EXIT FROM GLOBAL HEALTH RULE-MAKING
Hard cash is one thing, the wider political ramifications are another.
The implications of the U.S. exit from global health negotiations could redraw the dynamics with consequences for both sides – the U.S. and the rest.
The Trump order states: “…The Director of the White House Office of Pandemic Preparedness and Response Policy shall review, rescind, and replace the 2024 U.S. Global Health Security Strategy as soon as practicable.”
Specifically on global health negotiations, it states:
“…Sec. 4. Global System Negotiations. While withdrawal is in progress, the Secretary of State will cease negotiations on the WHO Pandemic Agreement and the amendments to the International Health Regulations, and actions taken to effectuate such agreement and amendments will have no binding force on the United States.”
INTERNATIONAL HEALTH REGULATIONS
Experts believe that the U.S. ceasing to be a part of these negotiations may require Congressional approval. In June 2024, WHO member states adopted the amendments to the IHR.
Gostin explained: “I don't believe that legally, the United States can withdraw from the International Health Regulations, not through unilateral decision of the President. Our participation in the IHR is based on the World Health Organization Constitution, which is a treaty signed, ratified and adopted by the United States.
I think, absent congressional approval for that decision, I believe that a unilateral decision by the president is reckless and unlawful. But that doesn't mean he will not try.
Let's just suppose he says to himself, okay, we are no longer in the IHR, that means that the United States has no say if any country in the world decides not to promptly report an outbreak or to do so accurately. It would signal to the world that the United States has no such obligation. It would make America decidedly less safe and less secure. It would make the world uncertain.I think it would unravel international cooperation.
We joined WHO through a joint resolution of the Congress, we ratified the WHO constitution, which is a treaty, and the President at a whim, can't unilaterally undo all of the legal obligations of the United States or the financial ones.
Sadly, we have a Supreme Court that's a super conservative majority, and have recently given Trump immunity for presidential decisions. It is almost as if there is an imperial presidency. But I do think this needs to be challenged.
While we can strategize on litigation, what concerns me after a year, would the court say the President has the power, even though it was Congress that got us into the WHO? In my view, you need Congress to get us out, but that's uncharted legal territory. We have a super conservative majority in the Supreme Court with four members of the court appointed by Trump himself.
I'm convinced that it's unlawful and that we remain a member of WHO at least for a year, that we have to pay all of our dues, and that we still are bound by the International Health Regulations and other existing treaties under WHO.
Getting Congressional approval for withdrawing from the IHR will be almost impossible, because you have got at least a few sane institutionalists in the Republican Party. Congress is a very dysfunctional body, and it's really going to be focusing on Trump's major priorities, which is immigration and tax reform. I don't think Congress would approve it.”
Gostin who is also Director of the WHO Collaborating Center on National and Global Health Law, is considering a law suit.
Former WHO legal counsel, Gian Luca Burci, who is also affiliated with the Global Health Centre at the Geneva Graduate Institute, told us:
"The executive order is not very clear with regard to the IHR. It erroneously mentions negotiations as if the amendments have not yet been adopted. The sentence in the executive order to the effect that 'actions taken to effectuate such agreement and amendments will have no binding force on the United States' reads to me as a forewarning that the US will reject the amendments adopted in May 2024, but what about participation in the IHR as such? The US's intentions remain unclear, and whether IHR parties can actually withdraw also remains unclear. "
ON THE PANDEMIC TREATY AND THE PABS MECHANISM
Apart from the IHR, Trump has also ordered ceasing participation in the three-year old negotiations towards a new Pandemic Agreement. This will inevitably have an impact on the dynamics in the negotiations that are expected to conclude in May 2025.
One of the most critical provisions in the treaty, is a new mechanism on Pathogen Access and Benefits Sharing.
Gostin said the following on the implications on these negotiations:
“…Our public health agencies like NIH and CDC, and our pharmaceutical industry based in the United States, is used to being first in line for data and first in innovation. So, Americans are used to getting the vaccines and the treatment first, but I think this will put us near the back of the line rather than at the front. It's not that the United States doesn't have great capacities on its own, but we rely on pathogen samples, genomic sequencing data, surveillance data, to understand mutations and the characteristics of circulating viruses. And without that, NIH won't know which priorities to fund. The CDC won't know which diseases to focus on and how. And most importantly, US pharmaceutical companies won't have immediate access to the information they need to innovate. So, I think it would affect us competitively. We are used to being first, but this could really push us near the back of the line that will not quite freeze us out, but will impede us significantly.”
WHAT WILL BE THE TRUMP EFFECT ON GLOBAL HEALTH?
Decisions and orders from the new administration flew thick and fast this week. From dismissing the recognition of sexual minorities, to instructions to pause external communication of U.S. health agencies, a range of these decisions will eat into how public health functions. This will impact not just Americans, but the very interconnected nature of how global health is addressed.
In his inaugural remarks, President Trump sought to “forge a society that is colorblind and merit-based” and vowed to “end the government policy of trying to socially engineer race and gender into every aspect of public and private life.”
The new administration has also sought to end censorship and restore free speech. The order on free speech says: “Under the guise of combatting “misinformation,” “disinformation,” and “malinformation,” the Federal Government infringed on the constitutionally protected speech rights of American citizens across the United States in a manner that advanced the Government’s preferred narrative about significant matters of public debate.”
The order will blow winds into the sails of disinformation forces. Such a move alone will have far-reaching consequences on how health is talked about and governed.
In addition, President Trump has nominated vaccine sceptics to key positions in health including Robert F. Kennedy Jr. as health secretary and Jay Bhattacharya, as head of the National Institutes of Health.
TAIL PIECE:
The American exit from WHO, is a not only a retreat from an international institution, but effectively from science and from internationalism. For global health diplomacy and international cooperation, this is both a blow and an opportunity.
WHO ANNOUNCES FREEZE ON RECRUITMENT & CUTS TO COSTS
Update [January 24, 2025, 21:45 CET]
Close on the heels of the Trump announcement that could squeeze its budget by nearly 20% in a matter of months, WHO was quick announce a freeze on hiring and an across the board cut in costs.
In a mail sent to WHO staff on January 23, 2025, DG Tedros Adhanom Ghebreyesus announced a hiring freeze, cuts in costs of travel and other expenses.
Excerpts:
“….As part of our strengthened risk management framework and operational planning for the 2024-25 biennium, the Regional Directors and I, with the support of senior management, have been working for many months to adapt to these challenges with twin strategic goals: raising more money, and becoming more efficient.
As you know, the United States of America has announced that it intends to withdraw from WHO. We regret this decision and hope the new administration will reconsider it. We are open to engaging in constructive dialogue to preserve and strengthen the historic relationship between WHO and the USA.
This announcement has made our financial situation more acute, and we know it has created significant concern and uncertainty for the WHO workforce. We share those concerns, and we want to explain the steps we are taking to mitigate the risks we face and protect our Organization’s work and workforce to the greatest extent possible.
On our first goal, our Member States have increased their assessed contributions and supported the first WHO Investment Round. We will continue to rely on their strong support, for which we are very grateful, while continuing to look for new sources of financing. This includes efforts through the WHO Foundation, which has started to deliver.
On the second goal, to reduce costs and realize efficiency gains, we have already taken several steps and are implementing the following measures with immediate effect:
Strategic alignment of available financing with key priorities: we are reviewing which activities to prioritize with a reduced resource envelope.
Human resources: we are freezing recruitment, except in the most critical areas.
Travel: we are significantly reducing travel expenditure and establishing targets, which will be monitored. All meetings must be fully virtual by default unless exceptional approval is sought and granted. Missions to provide technical support to countries should be limited to the most essential.
Procurement and general purchasing: we are limiting the replacement of IT equipment and renegotiating major contracts.
Office and support services: we are suspending office refurbishments, expansions and related capital investments, unless linked to security, safety or relocation to lower-cost places.
This set of measures is not comprehensive, and more will be announced in due course. The offices of the Director-General and Regional Directors will be responsible to lead implementation….”
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