The Impact of US Policy on Global Health

For most UN agencies, funds, and programmes, the US has been the largest contributor to date in terms of both mandatory and voluntary contributions. Until 2025, 22 per cent of the UN budget had been financed by mandatory contributions from the US. Taking voluntary contributions into account, this share amounted to 27 per cent in 2023.¹ Although the UN leadership had been preparing for worst-case scenarios and agencies such as the UN Population Fund (UNFPA) and the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) were fully aware of impending funding cuts by the Trump administration,² no one anticipated the complete abolition of the United States Agency for International Development (USAID), the freezing of development cooperation funds, or the cancellation of congressionally approved budgets.

In the first six weeks of Trump’s second term, 83 per cent of USAID programmes and 5,200 USAID contracts were terminated. Despite desperate attempts at stopping the eradication of international cooperation and its institutions in US courts, it quickly became clear that USAID’s achievements over the past decades would be undone in a very short time.³

In the 2023 fiscal year, health was still the second-largest area of US foreign assistance (22.3 per cent), while 27 per cent of this assistance went to economic development.⁴ According to a recent Lancet study, initiatives supported by USAID over two decades have helped prevent more than 91 million deaths across all age groups, including 30 million among children. USAID funding contributed to a 65 per cent decline in mortality from HIV/AIDS, to a 51 per cent decline in mortality from malaria, and to a 50 per cent decline in mortality from neglected tropical diseases.⁵

With the loss of US support, Tedros Ghebreyesus – the Director General of the World Health Organisation (WHO) – predicted 15 million additional malaria cases and 107,000 additional deaths by March 2025, which would undo the progress made over the past 15 years in eradicating Malaria.⁶

Withdrawal from the WHO, and defunding global health initiatives

During the COVID-19 pandemic and President Trump’s first administration, the WHO became the target of Trump’s criticism, and the President initiated his country’s withdrawal. During his second term, the US withdrew from the WHO again on 20 January 2025 with immediate effect even though a one-year notice period is normally required. The administration froze all US funding, rescinded the adoption of the International Health Regulations’ (IHR) amendments passed at the World Health Assembly (WHA) in 2024, and pulled the US out of pandemic agreement negotiations.⁷

According to the latest available data (2023), the US government was the largest contributor to the WHO, accounting for 25.18 per cent of mandatory and voluntary contributions to the overall budget.⁸ However, the loss of funding is only one aspect of the withdrawal. The denied access to expertise, data, and technology has also exacerbated the situation for the WHO. The global campaign to eradicate polio has been particularly negatively affected. The decision to withdraw from the WHO also ended the involvement of the US Centers for Disease Control (CDC) in the Global Polio Eradication Initiative.⁹ Access to the CDC’s global specialised poliovirus laboratory – a central hub for poliovirus testing, genomic sequencing, and polio outbreak detection – was blocked. The CDC-funded staff in polio-endemic countries – such as Afghanistan and Pakistan – had to be withdrawn. Similarly, surveillance and community engagement work in polio-affected countries had to be scaled back due to cancelled USAID funding.¹⁰

All this comes at a time when renewed polio outbreaks are being reported from French Guiana, Guinea, Indonesia, Somalia, Sudan, Yemen, and the Gaza strip and when vaccination campaigns are becoming increasingly difficult in conflict-ridden countries.¹¹

The termination of US funding for the Global Measles and Rubella Laboratory Network – which serves to combat both diseases – threatens the network’s existence because it was previously 100 per cent funded by the CDC. This termination coincides with surges in measles outbreaks in Europe, Canada, and the US.¹² According to a WHO report from November 2024,¹³ measles cases rose by 20 per cent in 2023. Outbreaks are now occurring more frequently and are becoming increasingly difficult to control, especially when vaccination rates fall below 95 per cent. Early detection is crucial but fails without adequate laboratory capacities.¹⁴

In order to save the network of more than 700 laboratories in 164 countries, the WHO Foundation¹⁵ is currently attempting to raise 3.6 million US dollars, with the philanthropic Elma Vaccines and Immunization Foundation already contributing 2 million. However, this amount is far from sufficient because a total of 9 million US dollars is needed, and it is clear that philanthropic organisations cannot fill the funding gap exacerbated by the US withdrawal from global health initiatives.¹⁶

Impact on the global health architecture

The WHO

During the 78th WHA in May 2025, WHO member states not only jointly adopted the pandemic agreement without the US, but also approved an additional 20 per cent increase in WHO contributions. In the past, these mandatory contributions to the WHO budget had been astonishingly low, accounting for only 16 per cent of the total budget. Most of the WHO budget had been based on voluntary and often earmarked contributions. Thanks to Germany’s leadership in the process, member states agreed in 2022 to gradually raise these contributions to 50 per cent by 2030, thereby giving the WHO greater planning security and flexibility.¹⁷

Adapting to the new realities of the loss of US financing, the WHO has had to reduce its budget planning for the 2026 to 2027 biennium various times, scaling back from 5.3 billion to 4.2 billion US dollars. However, a funding gap of 1.7 billion still remains for 2026.¹⁸

WHO Director General Tedros Ghebreyesus seized the moment of the WHA in May 2025 and – even before UN Secretary General António Guterres convened the directors of UN organisations in Copenhagen for a crisis meeting – initiated a structural reform of the WHO that addressed the high proportion of staff at its headquarters (2,938 WHO staff members in Geneva vs 9,452 worldwide). As a signal to donors, staff retrenchments began at the top, thereby resulting in a reduction in the Director General’s leadership team from twelve to five Assistant Director Generals, with 35 of the previous 65 directors remaining. A further 600 positions are to be cut in addition to the 409 employees who have already left the WHO since the beginning of 2025. However, performance-based personnel decisions were quickly denounced by some as retaliatory measures and vendettas, thereby further complicating the process.¹⁹ In addition to staff reductions, the WHO – like other UN agencies – is beginning to relocate to less expensive areas, such as Lyon (WHO Academy), Berlin (WHO Global Hub for Pandemic and Epidemic Intelligence), Dubai (WHO Global Logistics Hub), and India (WHO Global Traditional Medicine Centre). For the WHO’s Director General, the necessary structural adjustments are also an attempt to refocus the WHO on its core mandate: health for all.

UNAIDS and PEPFAR

Up to 2024, HIV/AIDS infections and related mortalities had been on the decline. After the epidemic’s peak of approximately 3.3 million new infections per year between 1995 and 1997, only 1.3 million new infections had been reported by 2024, representing a 60.61 per cent decrease over nearly three decades. Mortality also decreased by 71.36 per cent over around twenty years, falling from 2.2 million between 2004 and 2005 to 630,000 in 2024. Awareness-raising programmes and community outreach with the aim of combatting stigma in addition to – most importantly – the development of life-saving therapies and preventive medications lie at the core of this success.²⁰ With the defunding of development assistance, UNAIDS lost almost 80 per cent of its funding for project-related expenses that once went to community outreach, the monitoring of infection rates, and the “Stigma Index”. UNAIDS faces not only the loss of its own operational funding, but also uncertainties around the new operational realities of the US President’s Emergency Plan for AIDS Relief (PEPFAR)²¹ – another key pillar in the fight against HIV/AIDS.

For more than two decades, the US had been a steadfast leader in the global AIDS response through PEPFAR – the Global Fund to Fight AIDS, Tuberculosis (TB), and Malaria – and through its support to UNAIDS. PEPFAR has been estimated to have saved more than 26 million lives and to have prevented almost 5 million new HIV infections in 55 countries.²²

The freezing of the PEPFAR funds overnight led to the loss of jobs for health workers as well as to the closure of health facilities, to disrupted treatments, and to limited testing and prevention services. Currently, UNAIDS estimates that if HIV programmes supported by PEPFAR are permanently discontinued, this would lead to an additional 6.6 million new HIV infections and to an additional 4.2 million AIDS-related deaths between 2025 and 2029.²³

After months of uncertainty whether PEPFAR would be continued at all and on which level, out of a sudden it has been lauded as a flagship of the new America first global health strategy launched in September 2025. However, the complete redirection of PEPFAR support away from NGOs to governments, and the cut out of technical support and monitoring programmes leaves many questions. But without doubt, PEPFAR will be used as a leverage on recipients in the sense of America First.

Gavi and the Global Fund

The Global Fund to fight Malaria, HIV/AIDS, and TB – which received 1.65 billion US dollars from PEPFAR in 2024 for its HIV/AIDS programmes and a total of about one-third of its funding for its activities from the US – also had to adapt to the new circumstances. In the current 2024 to 2026 funding cycle, the Global Fund has already had to cut back on allocated money by 1.43 billion US dollars (i.e. 11 per cent of its budget). This leaves the current seventh funding cycle of the Global Fund with a financing shortfall of 2.3 billion US dollars, and it appears that contributions from private and philanthropic foundations will be insufficient to bridge this gap. The vast majority of the over 100 countries in which the Global Fund is active will experience funding cuts of ten per cent. Countries such as South Africa – where sufficient national resources could be mobilised – will face a 16 per cent reduction to their Global Fund allocations.²⁴ However, the 8th replenishment summit of the Global Fund, strategically hosted at the margins of the G20 summit in South Africa on 21 November, brought a positive surprise from the US. Although not even mentioned in the draft budget submitted to Congress, the US pledged 4.6 billion US dollars and maintained its pledging ratio in which for every 1 US dollar contributed, the Global Fund must secure 2 US dollars from other donors.

Since the Global Fund was established in 2002, the number of deaths caused by Malaria has fallen by 29 per cent, even as the population in the countries that the Global Fund supports has grown by 43 per cent. However, climate change, conflicts, resistance to insecticides, and a lack of funding are expected to jeopardise this fragile progress in some of the worst-affected areas.²⁵

The Global Alliance for Vaccines and Immunization (Gavi) is also trying to mobilise funding for its current replenishment cycle and is pledging a goal of 11.9 billion US dollars. With headwinds out of Washington, Gavi even postponed its Global High-Level Summit – originally planned for March 2025 – to the end of June 2025. It certainly came as no surprise that the US withdrew its support and that the pre-recorded speech by US Health and Human Services Secretary Robert F. Kennedy, Jr. turned into a harsh rebuke of Gavi in which Kennedy questioned vaccine safety and announced that the US would only re-engage with Gavi when the latter had “re-earned the public trust”.²⁶

However, the international community showed exceptional solidarity with Gavi, pledging more than 9 billion US dollars for the next five-year strategic period (2026–2030). The Gates Foundation contributed an additional 1.6 billion, and Indonesia – a former recipient of Gavi support – contributed 13 million.

Nevertheless, challenges remain for Gavi. Reaching the 2030 vaccine target of 90 per cent coverage for diphtheria–tetanus–pertussis, measles, and pneumococcal vaccines is becoming increasingly difficult. Thus far, only 18 of 204 countries have met this target. In order to reach vaccination targets, community engagement, trust-building, and tailored, culturally appropriate strategies for improving confidence in vaccines are needed. These are all areas in which funding is becoming scarce due to cutbacks in overall development assistance.

Loss of US leadership in global health research and development

For decades, the US government has invested in biomedical innovations, in developing new vaccines, in innovative treatments, and in breakthrough health technologies. These innovations have saved and improved the lives of millions in the US and around the world. Since 1999, 67 new health technologies for neglected and emerging diseases have been approved, including 12 new products for Ebola, 11 for Malaria, and 12 for TB, with resistant strains of TB currently spreading at an alarming rate. Beyond its positive health impact, these investments have brought substantial economic benefits to the US economy. Between 2007 and 2022, at least 86 per cent of all funding that the US government directed to global health R&D was reinvested in American companies and institutions. This investment has created an estimated 600,000 new American jobs, has spurred 104 billion US dollars in direct economic activity, and has yielded scientific knowledge that serves as a source of inspiration for further innovations.²⁷

The newly created government efficiency agency DOGE and the “Make America Healthy Again” (MAHA) approach have brought drastic changes not only for the CDC, but also for the National Institute of Health (NIH) and the Food and Drug Administration (FDA). Federal funding has been withdrawn from ongoing research, public data have been wiped, and thousands of jobs have been terminated, including those of CDC executives. Thus far, the CDC has lost about one-quarter of its staff, or approximately 3,000 employees. Moreover, the FDA has had to lay off around 3,500 employees, and the NIH has lost 1,200 jobs.²⁸

Once a leading actor in global health, the US has not only left a large void, but also become a source of misinformation. Although the US had been key in the negotiations for updated IHR passed at the WHA in 2024, both US Health Secretary Robert F. Kennedy, Jr. and US Secretary of State Marco Rubio incorrectly claimed that IHR amendments “significantly expanded the World Health Organization’s (WHO) authority over international public health responses [... and] have undue influence on [the US’s] domestic health responses”.²⁹ However, neither the IHR nor the newly negotiated pandemic agreement – which the US refuses to sign – interfere with the sovereign decision-making processes of any country in combating epidemics or pandemics.

How to close the financial gap

In global health, the international community is now facing the reversal of three decades of unprecedented progress. The dramatic reduction in US foreign assistance coincides with general funding cuts in development cooperation by other donors. Traditional donors such as the United Kingdom have reduced their foreign assistance budget by 40 per cent in 2025.³⁰

When the US announced its withdrawal from the WHO, China pledged an additional 500 million US dollars in funding for the organisation and agreed to increase its contributions by 20 per cent. This means that China’s contributions to the WHO will reach the previous level of US contributions.³¹ However, China generally has little interest in replacing US foreign aid. Chinese foreign assistance totalled 3.46 billion US dollars in 2024,³² which did not even come close to the 63.3 billion of US official development assistance (ODA).³³ Moreover, 85 per cent of China’s development finance is granted as debt (market-based loans and export credits) rather than as aid.³⁴ Confronted at home with rising criticism that money is being needlessly spent abroad, China might nevertheless double down on the already-established “Health Silk Road” and its own health diplomacy channels.³⁵ In any case, the Chinese government will seize the opportunity to present itself as being on a moral high-ground and as the more reliable partner for developing countries.

From the African continent, there have been increasing calls to view the crisis as an opportunity to reform the global health architecture and beyond. During the UN General Assembly in September 2025, Ghanaian President Mahama launched the Accra Reset Initiative, which – in addition to a committee of heads of state and government from Africa, Asia, and Latin America – also provides for a high-level advisory committee consisting of health and finance experts and representatives of the private sector. This initiative aims to redefine the existing relationships between donor and recipient countries and to shape these relationships around mutual accountability and responsibilities. During the autumn meeting of the IMF and the World Bank, head of Africa CDC Jean Kaseya went even further and questioned the entire development policy approach, arguing that to date, 60 per cent of the support provided for health systems in developing countries had been ineffective due to a lack of governance structures and coordination. However, he failed to answer the resulting question as to what responsibilities the ruling elites in the recipient countries bear in this regard because in his view, the lack of good governance also rests with them.

Irrespective of these recent calls for new approaches, donors and developing countries alike are looking to Germany when it comes to global health. Germany has long stood as a global leader not only in public health, but also in terms of shaping international cooperation on health through platforms such as the G7 and the G20. Germany has additionally developed into a hub for global health initiatives.³⁶ With the withdrawal of the US, Germany has taken on a new leadership role in global health. Although Germany’s engagement in key organisations of the global health ecosystem (e.g. Gavi, the Global Fund, the Pandemic Fund) is unmatched, this engagement cannot stand alone. Indeed, it must be accompanied by bilateral development assistance that addresses deficits in national health sectors as well as the socioeconomic and environmental factors that influence health. Phasing out bilateral health projects at a time when partner countries are being confronted with the financial constraints of a polycrisis is tantamount to putting the cart before the horse. Multilateral initiatives require sound national health institutions and implementing capacities by state and non-state actors down to the local level.

National governments in developing countries must acknowledge that health is not only a social good, but also a key element of productivity and economic growth. Global health should be viewed by donor countries not merely through the lens of solidarity and development assistance, but also as a matter of mutual interest and global interdependence. In an era of climate change, interconnected economies, and increased human mobility, diseases such as Cholera, Ebola, and Mpox cross borders easily, while tropical illnesses such as Malaria and Chikungunya are becoming more common in the Northern Hemisphere due to shifting weather patterns. Global health is as much a matter of human security as it is of economic security. Nothing has shown this more dramatically than the COVID-19 pandemic.

Andrea Ellen Ostheimer is Head of the Konrad-Adenauer-Stiftung’s Multilateral Dialogue Geneva.

1. United Nations System Chief Executives Board for Coordination (UNSCEB) 2025: Revenue by Government Donor, in: https://ogy.de/nuvd [30 Sep 2025]. ↩︎
2. Ostheimer, Andrea Ellen 2025: What a second Trump Administration will mean for multilateralism, in particular International Geneva, Country Reports, Konrad-Adenauer-Stiftung, p. 7, in: https://ogy.de/pub2 [30 Sep 2025]. ↩︎
3. Kates, Jennifer / Rouw, Anna / Oum, Stephanie 2025: U.S. Foreign Aid Freeze & Dissolution of USAID: Timeline of Events, Kaiser Family Foundation, 24 Oct 2025, in: https://ogy.de/s81d [28 Oct 2025]. ↩︎
4. DeSilver, Drew 2025: What the data says about U.S. foreign aid, Pew Research Center, 6 Feb 2025, in: https://ogy.de/b4fv [30 Sep 2025]. ↩︎
5. Cavalcanti, Daniella Medeiros et al. 2025: Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis, in: The Lancet 406: 10500, 19 Jul 2025, pp. 283–294, in: https://ogy.de/ccpn [28 Oct 2025]. ↩︎
6. Lei Ravelo, Jenny 2025: With US funding loss, WHO forced to make ‘terrible’ programmatic choices, Devex, 18 Mar 2025, in: https://ogy.de/8orx [30 Sep 2025]. ↩︎
7. The White House 2025: Withdrawing the United States from the World Health Organization, 20 Jan 2025, in: https://ogy.de/or9d [30 Sep 2025]. ↩︎
8. UNSCEB 2025, n. 1. ↩︎
9. The Global Polio Eradication Initiative (GPEI), founded in the 1980s, is a cooperation of the World Health Organization (WHO), UNICEF, Rotary International, the Global Alliance for Vaccines and Immunization, the Gates Foundation, and the US Center for Disease Control. ↩︎
10. Lei Ravelo, Jenny 2025: US decision to cut ties with WHO hurting polio eradication efforts, Devex, 10 Feb 2025, in: https://ogy.de/di65 [30 Sep 2025]. ↩︎
11. International Health Regulations Emergency Committee 2025: Statement of the Forty-second meeting of the Polio IHR Emergency Committee, WHO, 28 Jul 2025, in: https://ogy.de/ojsk [30 Sep 2025]. ↩︎
12. Emanuel, Gabrielle 2025: The Global Measles Laboratory is ‘under severe threat of collapse’ as U.S. pulls funding, National Public Radio, 20 Mar 2025, in: https://ogy.de/ehs3 [30 Sep 2025]. ↩︎
13. WHO 2024: Measles cases surge worldwide, infecting 10.3 million people in 2023, 14 Nov 2024, in: https://ogy.de/dp6d [30 Sep 2025]. ↩︎
14. Ibid. ↩︎
15. In 2020, the WHO Foundation was established in order to facilitate private sector engagement on global health and to allow the WHO to protect its independence and integrity. ↩︎
16. Branswell, Helen 2025: Philanthropies rush to save measles surveillance network pushed to brink of collapse by U.S. cuts, STAT News, 9 Jun 2025, in: https://ogy.de/rhdt [30 Sep 2025]. ↩︎
17. WHO 2025: In historic move, WHO Member States approve 20% funding increase and 2026–27 budget, 20 May 2025, in: https://ogy.de/h62l [30 Sep 2025]. ↩︎
18. Clancy, Dawn 2025: The WHO has to close a billion-dollar gap. Can private funding help?, SWI swissinfo.ch, 21 Jul 2025, in: https://ogy.de/1s73 [30 Sep 2025]. ↩︎
19. Fletcher, Elaine Ruth 2025: WHO Junior Staff at Risk as Pressure Mounts to Protect Top Jobs in Budget Cuts, Health Policy Watch, 26 Aug 2025, in: https://ogy.de/d9ny [30 Sep 2025]. ↩︎
20. UNAIDS Programme Coordinating Board 2025: 2024 Financial report and audited financial statements, UNAIDS/PCB (56)/25.11, 27 May 2025, in: https://ogy.de/d7ha [30 Sep 2025]. ↩︎
21. PEPFAR is the US Emergency Plan for HIV/AIDS Relief, which was launched in 2003 by US President Bush. ↩︎
22. PEPFAR / U.S. Department of State 2024: Latest Global Results & Projections Factsheet, 1 Dec 2024, in: https://ogy.de/sytd [30 Sep 2025]. ↩︎
23. UNAIDS 2025: About the impact of US funding cuts on the global HIV response, in: https://ogy.de/eadt [30 Sep 2025]. ↩︎
24. Green, Andrew 2025: Global Fund plans to cut $1.4 billion from grants it has already awarded, European AIDS Treatment Group, 10 Jul 2025, in: https://ogy.de/j4t8 [30 Sep 2025]. ↩︎
25. Jefford, Kasmira 2025: Global Fund boss warns aid cuts jeopardise progress against malaria, Geneva Solutions, 10 Sep 2025, in: https://ogy.de/xrlk [30 Sep 2025]. ↩︎
26. Cullinan, Kerry / Fletcher, Elaine Ruth 2025: GAVI Vaccine Alliance Secures More than $9 Billion from Donors – Despite US Ambush at Pledging Event, Health Policy Watch, 25 Jun 2025, in: https://ogy.de/o7on [30 Sep 2025]. ↩︎
27. Global Health Technologies Coalition (GHTC) / Policy Cures Research 2024: New Report Finds Public Spending on Global Health Innovation Delivers Blockbuster Returns, Saving Lives While Generating Billions of Dollars in Benefits Globally and Domestically, 14 Mar 2024, in: https://ogy.de/3h70 [30 Sep 2025]. ↩︎
28. Lovelace, Berkeley et al. 2025: Widespread job cuts begin at health agencies, NBC News, 1 Apr 2025, in: https://ogy.de/bbra [30 Sep 2025]. ↩︎
29. U.S. Department of Health and Human Services 2025: Joint Statement by Secretary of Health and Human Services Robert F. Kennedy, Jr. and Secretary of State Marco Rubio on International Health Regulations Amendments, 18 Jul 2025, in: https://ogy.de/h8ik [30 Sep 2025]. ↩︎
30. Landale, James / Graham, Chris 2025: Africa to be hit hard as UK foreign aid cuts revealed, BBC, 23 Jul 2025, in: https://ogy.de/k9qu [30 Sep 2025]. ↩︎
31. Fletcher, Elaine Ruth 2025: China’s 2026 WHO Fee Could Match US Levels Today – But Beijing Resists Planned Increase, Health Policy Watch, 10 Feb 2025, in: https://ogy.de/zyjz [30 Sep 2025]. ↩︎
32. China Africa Research Initiative: Data: Chinese Global Foreign Aid, 2003–2024, in: https://ogy.de/74ay [30 Sep 2025]. ↩︎
33. Organisation for Economic Co-operation and Development 2025: International aid falls in 2024 for first time in six years, says OECD, 16 Apr 2025, in: https://ogy.de/6uq0 [30 Sep 2025]. ↩︎
34. Custer, Samantha / Burgess, Bryan / Sritharan, Narayani 2024: Into the Breach: Will China Step Up as the U.S. Retreats on Global Development?, Policy Brief, 03/2025, p. 5, in: https://ogy.de/ck2l [30 Sep 2025]. ↩︎
35. Ibid., pp. 21 f. ↩︎
36. Lingenthal, Lukas 2025: Suddenly in the Lead – Germany’s New Role in Global Health, in: Facts & Findings 554, Konrad-Adenauer-Stiftung, 31 Jul 2025, in: https://ogy.de/qfrh [30 Sep 2025]. ↩︎