The second Trump administration has precipitated a seismic rupture in global solidarity and the institutional architecture of global health. In just over 20 months, the United States has withdrawn from the World Health Organization (WHO), recalled its scientific experts, and rejected the 2025 amendments to the International Health Regulations (IHR) as well as the WHO Pandemic Agreement. The administration has slashed foreign assistance, dismantled USAID’s global health capacity, and declined to expend congressionally appropriated funds.
At home, it has weakened core scientific institutions—undermining the Centers for Disease Control and Prevention’s domestic and international lifesaving work—while the National Institutes of Health has sharply curtailed international research collaboration. In place of longstanding multilateral commitments, Secretary of State Marco Rubio has advanced an “America First” Global Health Strategy, substituting coordinated global action with a fragmented patchwork of bilateral agreements untethered from epidemiological need or measurable health outcomes.
The world’s most vulnerable populations hit hardest
The upheavals in global health funding and governance are vast, but the clearest victims are the world’s most vulnerable populations. Despite congressional insistence on restoring funding for people living with HIV/AIDS, the administration appears to be deliberately withholding funds, placing lifesaving programs on the brink of collapse. A 2025 Lancet study projects that USAID cuts could result in more than 14 million additional preventable deaths by 2030. Mothers and very young children are likely to bear a disproportionate share of this burden.
Aid from the world’s wealthiest nations to lower-income countries fell by 23.1% in 2025, to $174.3 billion—the largest year-on-year decline on record, according to the Organisation for Economic Co-operation and Development (OECD). The United States accounted for the bulk of this contraction, with foreign assistance plunging by 57%, a reduction exceeding $35 billion. The repercussions are already cascading through the global health system. Gavi, the Vaccine Alliance the leading financier of vaccine procurement for low-income countries, is restructuring its 2026–2030 strategy to absorb major funding shortfalls especially from the United States and the United Kingdom. The WHO, meanwhile, is cutting approximately one-quarter of its workforce by mid-2026.
Taken together, these retrenchments are eroding the world’s capacity to detect emerging pathogens, weakening preparedness for future pandemics, and heightening vulnerability to both known and novel diseases—threatening increased morbidity and mortality on a global scale.
This trajectory is precisely the wrong one. A small number of countries have demonstrated the capacity to reallocate scarce domestic resources toward health priorities. Nigeria, for example, increased its health budget by $200 million to offset aid shortfalls, expanding investments in immunization and epidemic preparedness. Ghana lifted the cap on excise taxes earmarked for its national health insurance scheme, generating a 60% increase in funding. Such domestic measures—enhancing prioritization and fiscal autonomy—are essential.
Yet these examples are the exception, not the rule. For most low- and middle-income countries (LMICs), the rapid erosion of the global health architecture painstakingly built over decades is profoundly destabilizing. The result is a widening gap between need and capacity, with dire consequences for health security and equity. The repercussions extend to parallel global crises, including climate change, zoonotic spillovers, and mass migrations.
The way forward
In response, the global community—governmental and non-governmental alike—must recommit to solidarity, with a strengthened WHO at its core. Three priority measures could advance this vision.
Stronger coordination
First, the proliferation of global health institutions since 2000 has generated substantial overlap in mandates and functions. The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), Unitaid, United Nations Children's Fund (UNICEF), Gavi and the WHO—among others—should establish a joint working group to identify opportunities for financial and operational efficiencies, including clearer division of labor and pooled service delivery. The Gates Foundation, given its longstanding engagement across these institutions, could play a catalytic role in financing and convening.
The need for coordination is underscored by rising fragmentation and competition. Recent fundraising rounds by the Global Fund, WHO, and the World Bank’s Pandemic Fund—often launched in close succession—have competed for scarce resources, reinforcing inefficiencies at precisely the moment when strategic alignment is most needed.
The WHO must also fulfill its constitutional mandate as the world’s directing and coordinating authority on international health. It uniquely commands the legitimacy and trust of member states while possessing unparalleled technical expertise and longitudinal data to guide rational resource allocation. Prioritizing investment in WHO’s Pandemic Agreement and IHR (2025) would reinforce rules-based governance.
At its upcoming May session, the World Health Assembly will consider an annex to the Pandemic Agreement on pathogen access and benefit-sharing (PABS), underscoring international scientific cooperation and the equitable distribution of research benefits. Successful negotiation of the PABS Annex would help counter the fragmentation introduced by U.S. bilateral initiatives, which have cut their own deals for pathogen access.
Tailored allocation of resources
Second, rationalizing overlapping mandates must be grounded in a realistic assessment of the capacity of LMICs to assume greater responsibility for health programs historically financed through development assistance. The World Bank routinely evaluates country capacity using a range of fiscal and health system metrics that could guide more tailored allocation of responsibilities—identifying priority areas and sustainable levels of domestic investment. Many countries have already established benchmarks for health spending and system strengthening, providing a foundation for differentiated and strategic approaches to global health financing.
Innovative resource mobilization
Finally, global health institutions—notably Gavi and Unitaid, alongside the Global Fund and the World Bank—are already pioneering innovative approaches to resource mobilization. Options include expanding the solidarity airline levy that supports Unitaid, adopting variants of a financial transaction tax which—even if implemented by a subset of countries—could generate tens of billions of dollars annually, and introducing new or enhanced taxes on goods and services disproportionately consumed by wealthier populations.
Taken together, these mechanisms offer a pathway to more sustainable and equitable financing—reducing reliance on volatile donor contributions while strengthening the fiscal foundations of global health.
Despite the United States’ disproportionate influence in sustaining many LMICs and global health institutions, the international community can no longer depend on a single dominant actor. That reliance has exposed structural vulnerabilities that are now impossible to ignore. The future of global health must instead be built on genuine solidarity, equitable burden-sharing, and a renewed commitment to the central coordinating role of the WHO. Without such a reorientation, the world risks not only institutional fragmentation, but a profound failure to protect the health and lives of those most at risk.
The views expressed in this commentary are those of the authors and do not necessarily reflect the views of the World Health Summit (WHS). This commentary is part of the WHS Perspectives series on global health architecture. Additional perspectives from other contributors will be published in the coming weeks.
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