Donald Trump’s decision to withdraw the United States from the World Health Organization (WHO) will have major implications for global health. Hassan Damluji writes that while the organisation will survive, its ability to help the world respond to future health threats will be heavily constrained by the loss of US funding.

I was reminded of the extraordinary potential of multilateral institutions to bring our world together at a World Health Organization (WHO) event on genomics that I attended in October 2023. Not because of a large pledge of money or the signing of a grand treaty. It was the sight of an Israeli, and a Palestinian from Gaza, both experts in genomics, sharing a quiet moment and hugging each other during a coffee break. It was a reminder, in an increasingly polarised world, of how precious the spaces are where people from all sides are still talking to each other, working together on shared goals.

Donald Trump does not agree. His 2018 speech to the United Nations General Assembly set the tone. “We reject the ideology of globalism,” Trump barked at a stunned chamber. But the first term was heavier on rhetoric than action, and he didn’t get around to pulling the US out of the World Health Organization until July 2020, late enough that President Biden was able to reverse the decision before the one-year period – required for the exit to become official – had ended.

Trump’s second term has been quite different. Dozens of executive orders were signed on day one, including one that pulled the US out of WHO for a second time. This time, despite some obscure comments from the President, there is no indication that the decision will be revoked. Directed by the White House, Congress has gone as far as to cancel funding from 2024, the previous fiscal year.

Since late January, then, WHO has been in crisis, trying to respond to the loss of its biggest donor (the US provided $1.3 billion of the organisation’s $6.8 billion budget in 2023). It faces a $600 million budget gap in 2025, more than half of which represents the salaries of existing staff, who no longer have funds available to pay them. Taken together, the following two years see a budget gap of $1.9 billion.

The World Health Organization’s response

It seems incredible that the world, so soon after a pandemic which proved beyond doubt that health threats cross borders, would leave its global health agency so badly underfunded. If there was a lesson from COVID-19, regarding WHO, it was that we have far too thin a layer of international cooperation for managing health threats.

Even if the US felt its contribution to WHO was too high (although it provides no greater a share of funding than its share of global GDP), it is unconscionable that the world’s richest and most powerful country would decide that its fair share of global health efforts is precisely zero. But here we are. And so begins the response, one which is not short of resilience, nor even a measure of solidarity.

Internally, WHO has been working hard to rationalise its operations and make cuts to fit its new budget in a way that minimises the negative impacts on global health. As with any crisis, there lies an opportunity for improvement and efficiency in the discipline forced by these cuts. For example, disease programmes have often been siloed, leading to accusations of duplication and inefficiency (although many would argue that donors are primarily to blame for this siloing).

Now it is reported that some disease programmes, such as tuberculosis and HIV, will be integrated into combined programmes that share staff and operational aspects, such as surveillance systems. And beyond the more streamlined disease architecture, the organisation will be more laser-focused on efforts to build health systems and prepare and respond to health emergencies, particularly pandemics.

Resilience

The World Health Organization is resilient. It will survive this challenging period, and its renewed focus and emphasis on efficiency is welcome. But make no mistake: at a time when health threats are as serious as ever, with dangerous outbreaks more frequent than in the past, WHO’s ability to help the world respond will be more constrained thanks to these cuts. Its ten programmes will reportedly be reduced to just four, its sixty departments reduced to just thirty-four, and a huge but unknown number of its highly qualified staff let go.

It is completely untenable to suggest that philanthropy will step into the gap. The Gates Foundation is by far the largest philanthropic organisation in the world in terms of its annual spend, dwarfing all other actors, and it has already nearly “maxed out” the big donations to WHO it already makes. No other philanthropic actor could credibly make a big difference to the huge America-shaped hole in WHO’s budget.

For reference, the world’s second largest philanthropic organisation, the Wellcome Trust, has a total annual budget that is around the same as WHO’s lost US funding. The Wellcome Trust will not now suddenly shut down all its global programming and divert its entire endowment towards subsidising a single international organisation. Even if it did, some of the most important health research, which it currently funds, would be the casualty.

It is also untenable to hope for the funding gap to be filled by other donors. America’s retreat, not just from global health but from foreign aid altogether, has set off a domino effect, most notably in the drastic cuts made by the UK – until recently the world’s second largest donor. Nearly all government donors are now either expected to make foreign aid cuts or have already announced them.

Solidarity in a time of crisis

Where, then, is the solidarity? It comes in two forms. Firstly, in financing from the Global South, and secondly in diplomacy. On financing, a historic agreement has been reached to significantly increase the assessed contributions that all countries must contribute to the UN, based on the size of their economy. In a world of rapidly growing middle-income countries, like India, Malysia and Vietnam, much of the world’s economy, and its growth, sits in countries which are not “donors”.

Historically, “voluntary contributions” from donors have provided the majority of WHO funding. Now, that balance will shift. Increasing the assessed contributions – which will reach 50% of WHO’s overall funding by the end of the decade, represents an act of solidarity by the wide group of member states, many of whom suffer from deep poverty at home, to contribute to a common good.

Diplomatically too, the 190 remaining member states have been pulling together to build a better system. Just weeks after Trump’s hammer blow, this resulted in a remarkable achievement – a new Pandemic Treaty, mired in negotiation since the COVID-19 pandemic, was adopted by all WHO member states at the World Health Assembly annual gathering in Geneva.

The treaty still has some significant details to be hammered out – for example, how exactly will the sharing of data and the economic benefits of that data be managed? – but it remains an extraordinary rebuke to Donald Trump and the enemies of multilateralism that this symbolic agreement has been ratified so soon after his withdrawal.

And yet, we are only at the beginning of what will be a long four years for the international system. Far more resilience and solidarity will be needed along the way if we are to protect those spaces in which the world works together, in these times of crisis.

Note: This article gives the views of the author, not the position of EUROPP – European Politics and Policy or the London School of Economics. Featured image credit: Skorzewiak / Shutterstock.com