Funding shocks, political U-turns and weakened institutions have laid bare the flaws in a global health architecture long overdue for reform – and the need for courageous leadership to stop it from unravelling, writes Priti Patnaik, global health journalist and founder of the Geneva Health Files.
Global health governance hit a rough patch in 2025 – to put it mildly. It is tempting to lay all the blame at the door of the White House. But that would belie the complexity of a transition that has been long coming.
Those who work in global health – and the communities they serve – have had to crash-land the plane while simultaneously building a raft mid-air. It has been far from easy, because the rules of the game are changing so fast. Global health has been forced to reckon with structural financing and governance challenges. Whether lasting changes will come from the ground up, or from hollowed-out institutions in western capitals, remains to be seen.
The scale of the damage
The double whammy of the US’s proposed withdrawal from the World Health Organization (WHO), announced in January 2025 – the US is still a WHO member state, pending the settlement of its arrears –, followed by the swift cuts in overseas development assistance by a slew of donor countries, hit communities on the ground and institutions in Geneva and elsewhere hard. Hard enough to cost lives and upend health systems and livelihoods, exposing the vulnerabilities of the way global health is governed and administered.
The damage has been staggering in both scale and depth, with consequences that will be felt for many years to come.
According to the WHO and the OECD’s projections, external health aid dropped by 30 per cent to 40 per cent in 2025 compared with 2023. The impact on health services in low- and middle-income countries was severe.
HIV infections rose, the response to tuberculosis was disrupted, and the immunisation agenda, including for polio and measles, suffered serious setbacks, compounded by disinformation campaigns. Add to that an onslaught on science itself, these have had debilitating impacts on not only how global health is funded, but also how research is conducted, how data is gathered and how institutions are run.
UNAids has warned that without restoring prevention efforts, there could be 3.3 million additional HIV infections between 2025 and 2030.
Vast areas of global health have been affected, whether it is responding to health emergencies or to stubborn infectious diseases and non-communicable diseases. From regressive policies on sexual and reproductive rights to responding to climate change inaction – there is a cascade of impacts on global health.
The year witnessed growing attacks on science, including increased vaccine disinformation amplified from the US’s highest political levels. Precious time was invested in defending what we already knew to counter politically motivated, commercially driven disinformation.
Challenges in development coalesced into a greater crisis. It will take a while to fully delineate the effects of cuts to refugee and migrant support and their consequences on health. The health crisis in Gaza is but one egregious example of how much politics continues to further erode already decimated health systems.
Barely any aspect of global health has been untouched.
And worse may yet come, as the full implications of the blitzkrieg policy reforms in the US – and the domino effects they trigger elsewhere – come to bear.
Quick responses outpaced by long-lasting effects
Funding cuts to the WHO, UNAids and other institutions – alongside slashed science research budgets in the US – will have long-term implications for the field.
The WHO shrunk operations, restructuring both its areas of interventions and its workforce, while UNAids has cut staff by more than half.
Faced with abrupt uncertainty, institutions responded swiftly in a matter of months, sometimes weeks, by making across-the-board cuts in their budgets. It quickly became evident that other donors were also cutting down on funding. Few institutions were left with any choice. The WHO’s budget for 2026-2027 was cut back to $4.2 billion, after contentious deliberations by its member states. Not all agree with the kind of reprioritisation that the health agency has had to undertake – not to mention the implications for staff.
The Gates Foundation also emerged as the biggest contributor to the WHO, raising concerns about how global health priorities are set – and by whom.
Beyond direct budget cuts, institutions have had to deliver their services through health systems thrown out of gear, given that many developing countries depend acutely on foreign aid.
As the year coursed along, the first six months were spent second-guessing and playing catch-up to White House announcements, including a flip-flop on tariff measures affecting the cost of products, services and procurement.
Even for the biggest health agencies, better funded than the WHO, the year was humbling. Gavi raised $9bn against a target of $11.9bn for its 2026-2030 cycle.
The Global Fund to fight Fight Aids, Tuberculosis and Malaria fared better, securing $11.34bn for its activities between 2027-2929, including $4.6bn from the US. The Fund had sought $18bn in investment, arguing that it would prevent 400 million new infections and save 23 million lives by 2029.
Both these organisations also contribute to the WHO, though it is not yet clear how those contributions will be affected by tighter envelopes.
Normative role at stake
Funding cuts by sovereign donors have coincided with a rise in private financing for the UN agency, including from the Novo Nordisk Foundation.
Senior officials at the WHO and from donors have vowed to protect the organisation’s normative role. The unique selling proposition and the integrity of the institution rest on whether that promise translates into action, though it remains unclear how they will do so.
Although there is a lot of concern about the overall direction for global health governance, ultimately, the decisions will be taken by those who quickly step in to mould the transition.
Not all is bleak, or is it?
Despite swift geopolitics and trade considerations, WHO member states reached consensus and adopted the pandemic agreement in May 2025 after more than three years – a desperate and deft pushback against shrinking globalism. An annexe on a new pathogen access benefit-sharing system is still under negotiation, and countries must reach consensus by May 2026 ahead of the next World Health Assembly. A consensus on the annexe holds the key to the entry into force of the agreement.
But before the year wound up, it quickly became clear how fragile multilateralism is.
When the US and other countries pulled the rug from under health systems in the developing world, African leaders pledged resilience and sovereignty. These declarations had barely aged when the US sparked off another round of tremors through global health – this time through bilateral agreements promising aid in exchange for access to information. Kenya and Rwanda, among others, have already concluded such agreements, though not without pushback from local advocates and politicians.
These new bilateral deals pursued by the US may also have an impact on how countries share biological information.
Therefore, the negotiations at the WHO are crucial not only for the need to reach an agreement on a multilateral arrangement to access information on pathogens and share benefits, but also to illustrate international cooperation in a competitive bilateral environment.
The negotiations are illustrative of WHO member states’ ability to reach consensus but also leadership and creativity in policy design. It has the potential to alter how countries think about health systems strengthening during crunch time.
Worst-case scenario, the whole edifice could be at risk if most countries ended up prioritising bilateral considerations while sidelining the PABS annexe, effectively putting the wider agenda on pandemic prevention, preparedness and response on hold.
However, Covid-19 revealed that global health is a huge market. So, there will be opportunists who may salvage these negotiations to meet both commercial and security objectives.
Wanted: better leadership
In this state of deep flux, leadership is crucial. With so much at stake, one would expect deep strategic public conversations on the future of global health. There has been much hand-wringing at multiple talking shops across conference venues on what is coming next. But since global health is a club, much of the discussion will lead to decisions taken far away from public scrutiny.
Among the shifts that practitioners hope to see is decentralisation, new financing models beyond charity, a greater focus on primary health care amid the securitisation of public health and a new paradigm for a public goods approach to health. The challenge will be to reconcile demand for more justice and equity with efficiency and returns that donors will continue to expect.
Whatever comes next should be different from current approaches. Placating those who caused the crisis isn’t the leadership that communities need. Global health needs more leaders with backbone.
Some developing countries and emerging economies have been more prominent in articulating their health needs. However, moving the needle on the governance of global health will need both political and technical leadership, along with commitments and resources to govern this ongoing disruption.