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Curing the Discontents of Global Health
By guest contributor Olusoji Adeyi
Global health financiers and dependents are reeling from a barrage of decisions by the new government in the United States. To be clear, the second Trump administration’s withdrawal from the World Health Organization (WHO)1 and its erratic disruptions of funding for multiple channels of USA-funded Development Assistance for Health (DAH)2 are ill-conceived. Nevertheless, the more important question is: what do they mean for global health financing and institutions?
Global health leadership — via financiers, major institutions, and politicians across country income levels — is rife with obfuscation instead of forthright appraisals and reforms. For Geneva-based multilateral entities like Gavi and the Global Fund to Fight AIDS, Tuberculosis and Malaria, denial of reality was fueled by easy money from replenishment rounds, bankrolled by wealthy countries and potentates from private foundations. For WHO, an essential institution in technical matters, denial was sustained by implicit assumptions of entitlement to bigger budgets. For many politicians in the Global South, it was a matter of depending on DAH instead of taking responsibility to fund essential services for their own people. For USAID, it was a culture of refusal to learn, together with capture by a development industrial complex.3,4,5,6
The widespread furor over the USA’s recent announcements is unsurprising; after all, the status quo sustained a self-adulating global health leviathan. Mediocrity in global health leadership and institutions was reinforced by cheerleaders, such as an editorial in The Lancet,7 which blithely exhorted financiers to “reaffirm commitments to global health and wellbeing.” Given the waste and dysfunctions in DAH8, that unquestioning editorial and its like are irresponsible. Furthermore, they are compounded by craven displays of pre-emptive appeasement.9
Overhauling and reinventing global health require building on fresh thinking and nodes of policy wisdom, especially at the country and regional levels. Developing a viable global construct requires the courage to address uncomfortable tensions, principal among which are those outlined below.
Platitudes versus rigorous overhaul of WHO. According to WHO, taking account of pledges, signed funding agreements, and expected funding from partnerships, the organization has secured funding of US$ 3.8 billion for the next four years. That was 53% of what it sought, and increased predictability as compared to previous periods.10 Here is a thought experiment: if WHO were newly founded in 2025, with a provision that its budget would be permanently set at US$ 3.8 billion for every four-year period and adjusted only for inflation, what would be its true priorities in policy and programs? Being a global agency of the United Nations, it cannot much reduce the geographic scale of its work. Would it fundamentally rethink the scope of its work? Would it end the current style of voluntary contributions in which it performs, at the behest of special-interest financiers, the DAH equivalent of minstrel shows?
Rejecting versus venerating the “Lusaka Agenda.” An exemplar of global health’s ossification, the so-called “Lusaka Agenda”11 rehashes rituals of commitment to harmonization and alignment, then calls for current and future reforms to be done within the current institutional architecture. That is comforting for Geneva-based global health financiers and their primary funders, especially as they approach replenishment drives for Gavi and the Global Fund. It enables endless mission creep, in which self-perpetuating organizations, which have not definitively achieved their primary objectives, expand beyond their competence and swagger into health systems, pandemic preparedness and response, climate change, and seemingly anything associated with premature mortality. Funders of those institutions should have the courage to disavow the “Lusaka Agenda,” which seeks to entrench mediocrity and clientelism. Progress requires devising options that end North-South power imbalances and enable low and lower-middle income countries (LMICs) to take time-bound actions to finance their own health services. These measures would end the dependencies at the core of global health dysfunction.
Subsidiarity versus hypercentralization of epidemic/ pandemic preparedness and response. The extreme centralization of global health’s financial power, political power, and normative technical leadership in a few places — Geneva, Seattle, Washington DC, Brussels, London, Paris, and Tokyo — works against strategic interests of LMICs. Until this is resolved, much of the time spent negotiating treaties or agreements on epidemic and pandemic preparedness would be wasted. Regardless of good intentions, the solution to global health’s discontents does not lie in a negotiated settlement with the Trump Administration and WHO.12 It will not be resolved by a potential WHO convention on pandemic prevention, preparedness and response.13 Global health’s pathway to a new and durable relevance lies in subsidiarity — wherein nothing that can be done at country or regional level is done at the global level; in devotion to achieving real-time equity in access to essential diagnostics, medicines, vaccines, and all countermeasures for disease prevention and control;14 and in a global construct that serves, instead of lording it over people, institutions, and governments in LMICs.
Ineffectual coddling versus honesty on debt service payments by LMICs. Time and again, attention is drawn to the fact that many governments of LMICs are spending more on debt service payments than on health.15 Lost in these well-meaning entreaties are two questions. First, why should those countries be repeatedly bailed out of obligations they knowingly signed up for? Second, what percentage of their budgets are allocated to health after netting out debt service payments? Unless global health forums dare to address such unpleasant questions, they will continue to infantilize LMIC governments, with little or no progress toward sustainable self-financing of basic health services in those countries.
Avoiding or obfuscating these difficult matters means wishing that current geopolitical upheavals would pass, with the world returning to a familiar — and supposedly desirable — status quo in global health. That does not make strategic sense. These considerations recall the ending of Ayi Kwei Arma’s masterpiece novel, written on the back of a bus: “The beautyful ones are not yet born.” Despite the profound dysfunctions in global health, there is hope for a better future.
References
1. The White House. 2025. Withdrawing the United States from the World Health Organization. https://www.whitehouse.gov/presidential-actions/2025/01/withdrawing-the-united-states-from-the-worldhealth-organization/
2. Lee M, Knickmeyer E. 2025. US aid agency is in upheaval during foreign assistance freeze and staff departures. https://apnews.com/article/trump-usaid-foreign-aid-freeze-7d9c8cbcb241ec9a710feb8e883b9756
3. Norris J. 2012. Hired Gun Fight. https://foreignpolicy.com/2012/07/18/hired-gun-fight/
4. Devex Editor. 2012. USAID contractors react to ‘hired gun fight. https://www.devex.com/news/usaid-contractors-react-to-hired-gun-fight-78752
5. Adeyi O. 2022. Global Health in Practice: Investing Amidst Pandemics, Denial of Evidence, and Neodependency. 277 pages. World Scientific Publications. Pages 71-120.
6. Kerr, W. 2023. USAID’s largest-ever foreign assistance package doubles down on colonial aid. https://thehill.com/opinion/international/3836620-usaids-largest-ever-foreign-assistance-package-doubles-down-on-colonial-aid/
7. “The Lancet. 2025. Infectious diseases in 2025: a year for courage and conviction. Editorial. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00036-4/fulltext
8. Adeyi, O. 2023. Misguided charity: the bane of global health. BMJ Global Health. https://gh.bmj.com/content/8/9/e013322
9. Polus, S. 2025. Bill Gates on Trump meeting: ‘Frankly I was impressed’.https://thehill.com/homenews/administration/5092973-bill-gates-donald-trump-meeting/
10. WHO. 2024. WHO Investment Round: culminating moment at G20 Summit as leaders pledge. News release. https://www.who.int/news/item/19-11-2024-who-investment-round–culminating-moment-at-g20-summit-as-leaders-pledge
11. Future of Global Health Initiatives. 2023. The Lusaka Agenda: Conclusions of the Future of Global Health Initiatives Process. https://futureofghis.org/final-outputs/lusaka-agenda/
12. Gostin GO. 2025. A Negotiated Settlement with the Trump Administration & WHO, a Win-Win for Global Health Security. https://genevahealthfiles.substack.com/p/a-negotiated-settlement-world-health-organization-who-trump-financing-withdrawal-lawrence-gostin?utm_source=substack&utm_medium=email&utm_content=share
13. WHO. 2024. Pandemic prevention, preparedness and response accord. https://www.who.int/news-room/questions-and-answers/item/pandemic-prevention–preparedness-and-response-accord
14. Torreele E et al. 2023. It is time for ambitious, transformational change to the epidemic countermeasures ecosystem. Lancet. https://doi.org/10.1016/S0140-6736(23)00526-3.
15. United Nations. 2023. Africa Spends More on Debt Servicing than Health Care, Secretary-General Tells High-level Policy Dialogue, Urging Financing, Investment in Continent. https://press.un.org/en/2023/sgsm21809.doc.htm
About the author:
Dr. Olusoji Adeyi is President of Resilient Health Systems in Washington DC and Senior Associate at the Johns Hopkins Bloomberg School of Public Health. He authored the critically acclaimed book, “Global Health in Practice: Investing Amidst Pandemics, Denial of Evidence, and Neo-dependency.” He has served as Director of the Health, Nutrition, and Population Global Practice at the World Bank, and as founding Director of the Affordable Medicines Facility for malaria at the Global Fund.
Email: Olusoji.Adeyi@ResilientHealthSystems.com
Disclaimer: Views expressed by the author are solely his, and not necessarily those of any institution with which he is affiliated.
Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.