Air pollution in Delhi, the world’s most polluted capital city, is caused by several factors including traffic, industry and stubble burning.

Chad and Bangladesh  ranked as the most polluted countries in 2024, while Delhi, India was the most polluted capital city, according to the 2024 World Air Quality report produced by the Swiss-based IQAir.  But only seven countries worldwide met WHO air quality guidelines and Africa’s pollution levels remains under-reported. Pollution monitoring also fell victim to President Trump drastic cuts and rollbacks of environmental protections, as US embassies worldwide closed monitoring stations and disabled the US government’s airnow.gov data base.

Seventy-four of the 100 most polluted cities and towns are in India, according to the latest World Air Quality Report 2024, a slight improvement from 83 last year. Levels of a key microscopic pollutant, PM2.5,  declined 7% across the nation, averaging 50.6 micrograms/cubic metre or 10 times the World Health Organization’s (WHO) safe guideline.  Despite having the most polluted cities, India ranked fifth, globally, after Chad, Bangladesh, Pakistan, and the Democratic Republic of Congo in terms of national pollution levels.

Globally, only 17% of the almost 9,000 cities surveyed met the WHO air pollution standard, which is an annual average of 5 micrograms/cubic metre of the pollutant PM 2.5. This microscopic particulate matter, containing a cocktail of other pollutants that penetrate the blood and brain barrier, is the most widely tracked measure of air pollution.  Nationally, only seven countries: Australia, New Zealand, the Bahamas, Barbados, Grenada, Estonia and Iceland met WHO annual air quality levels, IQAir said.

However, a world map of pollution averages shows air pollution is primarily a Global South challenge. 

Most of the worst affected places are in Asia. Some in Africa, although only 24 out of 54 African countries or territories reported data in 2024. Still, this is a marked improvement since the first of these reports in 2017 had useable data from only three African countries. 

US State Department closes global air quality monitoring network

The rankings were released days after the new Trump administration’s move to shut down air quality monitoring at United States embassies worlwide.  In parallel,  the State Department deleted 17 years of  data from  US government’s airnow.gov data base – which had been a valuable source of reliable air quality data in resource-strapped countries like Chad.  This is likely to have a “profound” real-world impact on surveillance, according to the report’s scientists.

“The information collected at 80 global US embassies and consulates have proven to help protect public health and inform air quality policy… when US embassies began tracking local air pollution, host countries took action,” said Dr Christi Chester Schroeder, IQAir Air Quality Science Manager.

“IQAir estimates at least eight countries will completely lose access to all real-time air quality data because of this decision, nearly all of which are in developing countries.” 

In Asia, Iran and Afghanistan are not included in the report because of a lack of real-time data. 

The report is based on data from about 40,000 ground-level air quality monitors in 138 countries, although IQAir, a Swiss firm for air quality equipment, does not publicly provide a margin of error for PM2.5 concentrations used in this report. 

Caption: The world’s top-10 most polluted countries in 2024

Why India isn’t the most polluted

While it dominates the top 100 most polluted cities and towns, India’s expansive air quality monitoring network also captures levels in more rural and less polluted aeras – and that brought it’s national average down in comparison to other heavily polluted coutries, experts said.  

So the reasons Pakistan and Bangladesh ranked higher in overall pollution levels may be related to the limited scope of their air quality monitoring network – which tend to capture urban areas only. Cities with high PM 2.5 concentrations thus have a disproportionate impact on the country’s annual average concentrations. Chad also returned to the 2024 rankings – after being excluded in 2023 for a lack of data. 

Regional airshed solution for South Asia

Either way, the report makes for bleak reading for India and the rest of South Asia. Bangladesh, Pakistan, India and Nepal are ranked at 2, 3, 5 and 7. The capitals of all these countries are also in the top 10 most polluted cities.

India continues to lead the region in government monitoring infrastructure, operating more than half of the total stations, the report points out. Despite this, many areas in India remain under-monitored, particularly in smaller cities and rural regions.

Cities like Delhi and Lahore frequently experience hazardous conditions with seasonal spikes in pollution leading to emergency measures such as school closures and public space shutdowns.

“Air pollution pays no regard to country borders. The trans-boundary nature of air pollution is a serious issue in many regions around the world, and is no different with India and Pakistan,” said Schroeder.

“Airsheds need to be treated as regional international issues, not national issues. Cities in India and Pakistan, as well as Bangladesh and Nepal, share common sources of pollution – industrial emissions, agricultural burning, vehicle pollution, dust, etc. Despite years of evidence of trans-boundary pollution, regional cooperation has been underwhelming.”

The 20 most polluted cities in 2024. Source: World Air Quality Report,
Note: Delhi is the larger area and New Delhi is the capital area within it. The second position is Delhi’s highest ranking since this annual report began eight years ago. 

One of India’s foremost air quality government scientists, Dr SN Tripathi, believes that in South Asia, India will have to take the lead in proposing and establishing some kind of agreement or arrangement with other countries.

Airsheds within India and ability to analyse how air pollution is moving from one region to another. Tripathi, Dean at Kotak School of Sustainability, IIT Kanpur, calls for a “multilateral airshed approach sooner than later  to deal with this menace.” 

Delhi is the air pollution capital

The report’s scientists point out that while India’s population is nearly identical to the entire African continent, it has significantly expanded its air quality monitoring network in recent years. Experts say more such data should help in tackling the crisis. 

The world’s most polluted place is Byrnihat, an industrial town in India’s north-eastern state of Meghalaya. The annual average PM2.5 concentration was 128.2 micrograms/cubic metre. 

However, 2024’s data puts the main focus back on Delhi. The capital area of New Delhi, which has a municipality separate from the rest of Delhi, was the world’s most polluted capital.

The larger area of Delhi ranked second among nearly 9,000 places. This is Delhi’s highest rank since the annual report began in 2017. (Although this is the 7th World Air Quality report, IQAir has produced eight rankings since 2017 ,which have been shared with Health Policy Watch for this article.)

In stark contrast to the national decline, the pollution level rose in Delhi by 6% to 108.3 micrograms/cubic metre last year, the highest since 2019. Ironically, that is the year India’s first national clean air programme (NCAP) was launched. 

The report attributes Delhi’s pollution to vehicular emissions, a leading contributor to fine particulate matter (PM2.5), exacerbated by traffic congestion and fuel adulteration, as well as industrial and construction activities and seasonal burning of agricultural residue.

Northern India dominates global ranking

All the 74 Indian cities in the top 100 list are in northern India with none from southern India. 

About 65 of these are in the northern plain called the Indo-Gangetic Plain (IGP), from Punjab in the west to Bengal 2,000 km in the east. This remains a pollution hotspot, where meteorological factors trap pollutants and exacerbate winter smog. 

The Indian government plans to coordinate air pollution control plans in the IGP with a population of about 600 million as one jurisdiction.

While India’s PM 2.5 averages 50.6 micrograms (population-weighted), a back-of-the-envelope calculation of average pollution in the IGP states shows the level of PM 2.5 to be higher by about a fifth. 

The location of the 74 Indian cities in the top 100 most polluted ranking of 2024 World Air Quality Report.

The challenge is that each state is a separate political entity but air pollution obviously moves across political boundaries.

Tripathi advocates the airshed approach as the framework “to approach the problem with common or shared resources.
To get more bang for the buck.” He estimates that pollution can come down by two-thirds if the burning of waste outdoors and of polluting fuels (like coal, dung and wood) inside homes is stopped. 

China’s Air Pollution Dips 

Pollution levels declined in over 320 cities in China, including major cities such as Beijing, Shanghai, Chengdu, Guangzhou, and Shenzhen. But levels rose in almost 130 other cities. 

Officials have set ambitious goals to lower the national annual average PM 2.5 concentration to below 28 µg/m³ by 2027 and below 25 µg/m³ by 2035. Special attention is being given to the Beijing-Tianjin-Hebei region at the provincial level.

Warning for Southeast Asia’s most polluted country

Air pollution in Indonesia’s captial of Jakarta.

Air pollution in Indonesia decreased by 4% in 2024 compared to the previous year, averaging 35.5 micrograms. However, the report warns of a clean energy challenge.

The country is the world’s leading producer of nickel, a vital mineral for clean energy and storage but to extract it takes a lot of energy. And for this, it’s increasing its coal power capacity which grew 15% over a year till July 2024. 

Coal burning generates two-thirds of Indonesia’s electricity. Despite declining pollution, it remains the most polluted country in Southeast Asia. 

Vietnam air pollution’s cost

In Vietnam, air pollution has been estimated to cause a loss of around 4% of the GDP. Acute air pollution events in Vietnam have severely impacted daily life, with disruptions to air travel leading to flight diversions at multiple airports. In 2024, there was a small reduction in pollution from 29.6 to 28.7 micrograms. 

Vietnam’s government, international bodies and various organisations are empowering citizens through information campaigns to raise awareness, take preventive action and also expand air quality monitoring for public health action and academic research. 

Community initiatives are promoting sustainable agricultural practices, such as reducing straw burning, while advocating for responsible household waste disposal to minimize pollution.

The cleanest air was found in Hawaii’s Honaka’a, in the United States. It is ranked 8,954th and the PM 2.5 average was one microgram/cubic metre of air. 

Image Credits: Raunaq Chopra/ Climate Outreach, IQ Air, IQ Air, IQAir, Google maps, Aji Styawan / Climate Visuals.

A patient with diabetes attends a check-up at a district hospital in Kigali, Rwanda. Investment in NCD prevention, treatment and care at primary level can save millions of lives.

Almost five million lives could be saved annually if low- and middle-income countries (LMICs) invested 1% more of GDP in public healthcare spending – and used at least 40% of this to prevent and treat non-communicable diseases (NCDs).

This is according to Airfinity research commissioned by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), which issued a “Call to Action” on NCDs on Tuesday.

The research is based on “implementing existing cost-effective interventions such as cardiovascular disease management, diabetes screening, and respiratory care”, according to the IFPMA.

 

“The data supports growing consensus that more funding is needed to bend the curve on NCDs,” the pharmaceutical body said, “urging collective action across the globe” ahead of the United Nations High-Level Meeting on NCDs in September.

NCDs such as cancer, diabetes, cardiovascular disease, lung disease, mental health, and neurological disorders cause almost three-quarters of global deaths. Eight out of 10 premature NCD deaths take place in LMICs

Investment in NCD prevention and control could yield an annual seven-fold return in LMICs within a decade, according to 2021 World Health Organization (WHO) calculations

Lifestyle interventions including healthy diet and exercise, and primary healthcare could lead to an expected $230 billion economic gain by 2030, the WHO found.

But NCD prevention, early detection, treatment, and control “remain severely underfunded and under-prioritized by both governments and global donors,” according to the IFPMA.

“Low awareness” by “decision-makers, affected individuals, and general population” and “fiscal challenges” were the main reasons for the underfunding, according to the WHO and the World Bank.

As a result, on average some 60% of treatment costs are being carried by patients in LMICs. These out-of-pocket payments for NCD treatment and care push approximately 100 million people worldwide into extreme poverty every year, according to the NCD Alliance.

Access to medicines

The IFPMA noted that “over 1,400 medicines have been approved for NCDs in the past 10 years, which have transformed how we fight disease, and are improving the lives of hundreds of millions of people living with chronic conditions” and “a further 9,600 NCD medicines [are] at various stages of research and development”.

However, there are “significant barriers and delays in ensuring these medicines and vaccines can reach the people who need them, and there are still NCDs for which there is not adequate treatment”, the IFPMA noted. 

The IFPMA is working with partners in Access Accelerated to assist governments to identify a “suite of sustainable financing mechanisms” for NCDs including “health taxes, private or community-based health insurance programs, debt-for-health swaps, health savings accounts, performance-based financing (social impact bonds), blended financing, and mobile health financing solutions”.

Redirecting existing fossil fuels subsidies and increasing taxes on tobacco, alcohol, and unhealthy foods are options for LMICs to raise finances to address NCDs, the IFPMA report notes.

Collective action

It called for collective action to enable innovation, mobilise investment, drive implementation and ensure the accountability of government and key stakeholders to improve on prevention, treatment and care of NCDs and mental health.

“A political declaration that includes these recommendations can drive a vision for 2050 forward where there are fewer premature NCD deaths, reduced health systems strains, and healthier societies everywhere,” according to the IFPMA.

IFPMA Director General Dr David Reddy said that the UN High-Level Meeting “provides a real opportunity to refocus attention on how cross-sectoral partnerships can help increase access to cost-effective medicines and vaccines in a way that can transform – and even save – the lives of millions of people worldwide.” 

Supporting the call, Dr Kimberly Green, PATH Global Director for Primary Health Care, said that “improving accessibility of essential medicines and health products has been underrepresented in discussions” ahead of the High-Level Meeting. 

PATH acts as the Secretariat for the Coalition for Access to NCD Medicines and Products.

Green said that action is needed to “reduce catastrophic out-of-pocket health costs for people living with these conditions”, and that additional investment was needed to treat NCDs “through strengthened primary health care”.

Image Credits: G Lontro/ NCD Alliance, Airfinity, IFPMA.

A WHO outreach worker checking women in Beni, Democratic Republic of Congo, for fever as part of Ebola virus tracking.  Ensuring WHO’s core functions in countries can continue is paramount as the Organization adopts a broad set of austerity measures.

To save the World Health Organization (WHO), move staff to regional and country offices; cut posts at the top not only bottom; reduce gig workers rationally; and create a merit- and equity-based HR strategy for all levels of the organization, urge critics 

The number of WHO’s top-ranked directors (D2), the highest level of staff before the Director General’s senior leadership team, has nearly doubled since Director-General Dr Tedros Adhanom Ghebreyesus took office, with 75 people holding D2 positions in July 2024 in comparison to only 39 in July 2017. 

The cost of WHO’s top-level echelon have grown even faster, with roughly $92 million spent on just 215 Directors, the DG and his 11 member senior team – and around $130 million if you consider P6 staff  who fill many of the same management functions, according to a detailed analysis of available data by Health Policy Watch

Most of new D2 positions are at WHO’s Geneva Headquarters, the costliest location of the global agency, where the number of senior directors increased from 29 in 2017 to 46 as of July 2024. 

Source: WHO Human Resources Update, Workforce data, 31 July 2024.

The other region that saw a big increase in directors was Africa, with eight D2 posts in 2024, as compared to only one in 2017.  All other WHO regions saw an increase of 50-200% of D2 as compared to 31 July  2017, one month after Tedros took over. 

This is buried in a bi-annual WHO report on human resources that was presented at last month’s Executive Board.  Health Policy Watch reviewed the past 10 years of reports, published twice a year, to look at HR trends just prior to July 2017 when the DG assumed office, and since.   

Critical juncture for WHO facing $600 million deficit in 2025

The World Health Organization Headquarters in Geneva, Switzerland

This revelation come at a critical time in the organization’s financial future in light of the dramatic United States withdrawal from the organization, the organization’s top contributor which provided about 15% of WHO’s total income in 2022-23

On Friday March 28, WHO Director General Dr Tedros Adhanom Ghebreyesus sent an email to all WHO staff telling them that the organization’s 2025 budget deficit, originally estimated at $175 million now stands at $600 million, due to the United States’ non-payment of dues owed for 2024 and 2025, as well as shifts by other countries from health to defence funding, according to the email, seen by Health Policy Watch.

For 2025, the US owes about $130 million, but it’s doubtful that the administration of new US President Donald Trump, who announced his intent to withdraw from the agency in January, will actually fulfil the US legal obligation to pay its dues until the withdrawal is formalized in January 2026.   

Internally and externally, Dr Tedros has already announced a range of tough belt-tightening measures to compensate for expected 2025 budget shortfalls and to meet a 2026-27 budget,  of about $4.9 billion, or $2.45 billion a year. 

These have included; a reduction of the planned two-year budget envelope to $4.2 billion, or just $2.1 annually, approved by the WHO Executive Board in February;  a worldwide freeze on the recruitment of all new staff; dismissals of temporary staff and consultants; and the creation of three new WHO staff and administration committees to evaluate further new measures to be taken in terms of staff, resource mobilization and “organizational efficiencies and programme prioritization.”

Fixed term extensions curtailed

In an email sent by WHO division heads on Thursday, and seen by Health Policy Watch, WHO staff were informed that all personnel on temporary as well as fixed term contracts – which typically are renewed every two years – would only be extended “for a maximum of one year. Some contracts may be extended for six months only – if funding is not available and functions are planned to be deprioritized.”  

The one-year limitation on new or renewed fixed term contracts was confirmed in yet another memo from the Assistant Director of Business Operations, Raul Thomas, sent to all staff late Monday.

Meanwhile, earlier last week, an email was sent to all staff who would be 55 or older, as of June, early retirement with four months of salary if they opted to take the offer by 15 July.

The combined measures are stimulating more cries of distress from more WHO staff inside the organization. There are also mounting claims that measures disproportionately hit at mid- and lower-level staff who lack the tenured protection of the most veteran staff on “continuing contracts”.  Continuing contracts, which were discontinued in 2014, are expensive to cancel with staff entitled to up to 12 months net base salary – or an offer of a comparable post in another WHO office or region – where costs may, at least, be cheaper.

WHO sources told Health Policy Watch that a plan is also taking shape that would see a dramatic reduction in short-term consultants, whose numbers have ballooned since 2017.

As of July 2024, there were some 10,000 contracts for roughly 6,000 full time equivalent positions (FTEs) – although the latter number is an estimate in the absence of complete HR information on the actual number of FTEs represented by the nearly 5000 “Special Services Agreements” that regional and country offices issued in 2024.   

Other moves being considered are said to include shifting of key functions to less expensive and more relevant country locations and pooling administrative functions for greater efficiencies – moves that are likely to be welcomed by member states. 

These also could finally fulfil a longstanding WHO goal to ensure that roughly three-quarters of staff are based in regional or country offices. Since Tedros took office, the proportion of staff in headquarters have been declining but only very gradually – from 30.5% in July 2020 to 28.8% in July 2024, for instance.  

The proportion of WHO staff based in country and regional offices has steadily grown, but nearly one-third of staff still remain at the Geneva headquarters.

Elephant in the room

Amidst the cost-cutting moves, the elephant in the room is whether scrutiny will be extended to the most politically sensitive positions in senior management such as the bloated number of D2 posts. 

While voluntary retirement offers of staff aged 55+ might lead to some such reductions, it’s highly unlikely that directors in the most secure and highest-paying positions would grab offers to leave, based on only four months additional pay. 

But if more savings are not achieved in WHO’s most senior ranks, then the jobs of more entry-level WHO staff at P1-P3 are likely to be placed on the chopping block instead. This will curtail the entry of young  professionals, the organization’s “worker bees”, just when WHO may need them the most. 

That would be regrettable, critics say, as the salary of a single D2 at the highest grade can cover the costs of three to four P1 staff at entry level, or two to three P2 or P3s. And entry and mid-level professionals are also the future “lifeblood” of the organization.  

Half or more of P1-P3 staff are on short-term contracts of less than a year, which  are easiest to eliminate.  An increasing number of P-level staff in the Geneva headquarters are working on rolling contracts of only 60-days, which may include health insurance but no other benefits.

WHO’s 2024 salary scale for profesional staff.  Gross salaries, however, comprise less than one-half, and net salaries, one third or less, of the real costs to the organization.

Additionally, gross salaries published by WHO comprise less than half the real costs to the organization, and net salaries about one-third, as per the 2024 published breakdown of payroll costs for P and D staff reflected in Table 21 of the 31.07.2024 HR update.

They do not include, for instance: post adjustment for Geneva (83% of net base salary in 2024 and 66.7% in 2025); education grant and boarding (up to $33,000 per child), dependents’ allowances, home leave and relocation grants, as well as WHO pension and insurance costs  – all of which are comparatively higher for WHO’s senior professionals who, as international recruits, have more entitlements.

Senior management overall increased by 9% since 2017 

WHO Director General Tedros Adhanom Ghebreyesus and Deputy Director General, Mike Ryan, brief the WHO Executive Board in January 2024.

The 2017-2024 comparisons shared with the EB in February shows that there has been a net 9% increase in the numbers of senior management (P6/D1 and above) positions since 31 July 2017 when Tedros assumed the reins of the organization.   

The biggest increase was in the most expensive D2 positions, which more than doubled. Other senior management numbers remained relatively stable with a slight decline in the total number of P6/D1 staff. 

Increases were seen across all regions except Africa and South-East Asia. In Africa, the reductions in P6/D1 staff numbers offset the 700% increase in more costly D2 positions. 

South-East Asia was the only region to see a net decline in total senior management positions by 23%.  Europe saw the biggest net increase of 30%, the Eastern Mediterranean and Western Pacific Regions, an increase of 21% each; and 10% in WHO’s Geneva headquarters. 

The WHO region of the Americas, or the Pan American Health Organization (PAHO) operates autonomously and thus is typically not included in WHO’s global HR reporting. 

D2 is the highest level of professional staff who are supposed to be hired through competitive, merit-based civil service competitions – although  politics, cronyism and geographic balance traditionally play a role in such appointments as well. 

WHO failed to respond when asked repeatedly by Health Policy Watch about the increase in D2 positions, and other aspects of staffing costs and priorities, prior to publication. At a Tuesday UN Geneva press conference, just after the article was published, WHO Spokeswoman Margaret Harris had this response: “we’ve been doing a lot of work on cost containment, on changing, as I mentioned, how we are funded, but what we do with our funds is critical, and particularly looking at where our programs have most impact, and our programs have most impact in the countries where we’re needed.

“What’s really been happening is a big transfer of funding and staffing and commitment at country level away from HQ, and that has been really the core of the transformation process, really the core of what Dr Tedros brought it to, who in his thinking when he became director general, it has been a slow process, and for sure, you know, the cold winds of economic rationalization are speeding that up.”

Senior leadership team also swelled between 2017-2021 – but since rolled back  

WHO’ Director General Dr Tedros Adhanom Ghebreyesus’ Senior Leadership Team

Above the D2s, there are currently 10 Assistant Director Generals and a Deputy Director General (Mike Ryan), comprising WHO’s Geneva-based “senior leadership team”. All are directly appointed by the DG.  

Five Regional Directors fill out the set of 17 staff in “Ungraded” (UG) positions. PAHO’s Regional Director is paid for by the PAHO budget, financed and managed separately by member states in the Americas region. 

Shortly after Tedros took office in July, 2017, the number of ADGs and others in  “ungraded” positions at headquarters also began to grow, peaking at 18 (not including the DG), in  December 2021. 

But those numbers shrunk again.  As of the July 2024, the headcount of the DG’s ungraded appointees was 11 – just one more than the 10  on the team of former DG Dr Margaret Chan prior to her retirement, as per the WHO HR report of December, 2016. 

Grade inflation?

Numbers of Staff by Grade and Category, HR Update Tables, as of 31 July 2024.

Along with the increase in D2s, the parallel decline in P6/D1 staff in HQ and three regions – Africa, South-East Asia and the Eastern Mediterranean – since 2017 suggests a kind of “grade inflation” whereby serving D1s have, over time, received promotions to the higher-paying grade.  

Additionally, staff in P6 and D1 positions, who share the same pay scale, are sometimes combined within WHO’s HR tables – making it difficult to tease out nuances of staff movement in the upper grades.  

Typically, P6/D1s commonly serve as the heads of technical units or departments  – managing the day–to-day activities globally of WHO’s staff of 9,473 international and local professionals and administrative support, in 2024. That 2024 workforce also included more than 7,500 people on consultancies and other non-employment contracts – making for a global workforce of more than 17,000 in 2024.

Costs of most senior staff  to WHO: nearly $130 million 

In a period of belt-tightening, it is the costs to the organization of staff positions, by grade and region, that represents a critical bottom line in weighing budget choices and priorities.  Without their transparent assessment, decisions are more difficult to make, as well as to challenge. 

Those costs, stratified by grade and by region, are not publicly provided by WHO in its bi-annual HR reports to the EB or the WHA. WHO also failed to reply to repeated requests by Health Policy Watch to provide details on actual costs of staff at all grades and levels to the organization

However, reliable estimates can still be made, based on available published data.  We analyzed the data on gross and net base salaries for P1 to D2 staff, as published by WHO in its 2024 Staff Regulations and Staff Rules, against data on the proportion of net base salary to total Organizational costs, reported in the annual HR report. 

Those show that net base salary costs represented just 34-37% of the total organizational costs for all professional staff in 2024 – from  the lowest-level local and temporary hires to senior management. 

Published net salaries comprised only 34-37% of total Organizational costs for all professional staff, including local and temporary hires in 2024.

For senior staff, who generally are international recruits with large entitlements, the proportion of net base salary to other payroll costs would be even higher than the average since locally-hired P staff receive far fewer benefits, while  temporary staff on contracts of 60 days get almost none.  

In other words, the published salary levels for senior staff likely represent about 30%, of the total organizational cost of that position – once generous UN-mandated allowances for “post adjustment”; education, home leave, relocation and other entitlements exclusively available to international recruits are included.  

We tested this by comparing actual gross and net salary payments of existing or recently departed WHO P staff who receive entitlements, with the posted salary scales. The results also aligned roughly with a “30% rule”. 

Based on these assumptions, the average cost for each of the 54 D2s based at headquarters and the Africa Region was estimated at about $430,000. This calculation is based on a D2 at the mid-level Step VI of the salary scale with an average gross income of $171,895 and net base of $128,951. In other regions, costs for 21 D2s were estimated at a slightly lower average of  $420,000.

Together, the costs are estimated to approach exceed $33 million for D2 posts globally.   

Considering these assumptions, roughly $92 million can be attributed to just 215 of the organization’s most senior staff. If one includes P6 staff, who have more daily, hands-on management responsibilities, the costs of WHO’s 301 most senior staff rises to nearly $130 million.

Sources: Appendix 1 to WHO staff rules 2024, effective as of January 2023, WHA 2023: salaries of staff in ungraded positions and 31 July 2024 HR update: Estimates are based on costs of a D2 at Step VI and a D1/P6 at Step X of the published salary scale.

Costs to WHO of salaries unpublished

It should be emphasized that these figures are an estimate as average real costs of staff salaries by grade, location and years of service, are not routinely published by WHO in its HR tables – only the aggregate of payroll costs for all professionals in comparison to net base salary. And these, as well, may not fully represent all organizational costs.

However, proportionally the cost to the organization for senior staff is likely to be larger than the average for several reasons. High-level professionals are more likely to be older with children in high school or university – and thus entitled to the maximum education allowances of roughly $33,500 per child annually for tuition and board through four years of university. Such recruits also may receive more in dependency allowances, health insurance, relocation grants, and home leave. 

Senior P and D staff also are more likely to have been internationally recruited  and entitled to the  “post adjustment allowances” for cost of living in expensive locations. In pricey Geneva, for instance, the post adjustment was 83.6% of the net base salary in 2024. 

In January 2025, that declined to 67.6% as part of a UN move to reduce overly generous location allowances.  Concurrently, salaries of all WHO professionals’, directors and senior leadership increased by 9.5% on a “no-gain, no-loss” basis.

Pay rates for senior leadership, as confirmed by the EB in February, were $293,003 gross and 218,602 net for the DG;  $235,064 gross and $170,642 net for the DDG; and to $213,655 gross and $170,642 for ADGs and RDs.  

Salary scales for WHO professionals and directors as of January 2025, as per report the DG’s report to EB 156 (27.6). Gross and base salaries do not include education grant and school boarding (up to $33,000 per child), dependent allowances, home leave and relocation grants, as well as costs to WHO of its contributions to pension/insurance.

WHO’s professional staff work tax- free in host and home countries, with the exception of US citizens or employees based in the the US. For WHO employees who are American citizens working at home or abroad, the organization foots the bill for that staff member’s salary-related tax payments to the US IRS so that they are not penalized in comparison to other international staff.  That adds further to costs.  

Some good reasons, but… 

Security rushes to extract WHO DG Dr Tedros Adhanom Ghebreyesus from Sanaa airport’s waiting room 26 December 2024, where the DG narrowly escaped an Israeli bombing attack that injured a crew member of the UN airplane waiting for him on the tarmac.

There are some good reasons why WHO professionals enjoy a traditionally large basket of benefits.  

International staff typically uproot themselves and their families across countries, continents, and cultures, making relocation and “home” leave visits every two years essential to attract the highly qualified scientists, economists, doctors, nurses and other medical  professionals that WHO desperately needs. 

For children who cannot easily integrate into local school systems, culturally or language-wise, education grants provide them with an opportunity to attend a boarding school or a local international school. 

Most WHO staff do not accumulate points in their home countries’ pensions and social security systems while employed with the UN. And in an era of dual career families, many staff also  continue to maintain households in their home countries with all of the expense that involves.  WHO staff, including high-ranking staff, may be subject to considerable risks. Witness the DG’s Tedros and Deputy DG Mike Ryan’s recent trips to a range of epidemic hot spots, including to support Tanzania’s response to an outbreak of Marburg virus and Uganda’s Ebola response, not to mention conflict zones, such as Afghanistan and Yemen – where the DG was caught up in an Israeli air attack on Sanaa’s airport on 26 December. 

Finally, WHO staff salaries are not set by the organization. They fall in line with salaries across the wider UN civil service system. But when all is said and done, the sum total of Geneva’s high “post adjustment”; education and other benefits, on top of a tax free salary as well as certain customs benefits, offers the most senior staff at WHO headquarters a very generous net income in comparison to comparable jobs elsewhere. 

“When I moved back to the United States, I had to take a big salary cut,” one former WHO director told Health Policy Watch, speaking on the basis of anonymity. “It raises questions when senior WHO team members earn more than US Senators or the ministers of health in their home countries.”      

The consultancy conundrum 

At the opposite end of the scale from the highest-paid directors and managers, contracts for short-term WHO consultants more than doubled between 2016 and 2023.  These “consultants” are one of three “non-staff” categories under which contracts are issued. All in tall, the growth in short-term, non-employment contracts and consultancies dwarfs significant increases in high- and lower-ranking staff alike. 

Just prior to the COVID-19 pandemic, the number of consultants was already increasing, although it only totaled 1,169 people, and 303 Full-time Equivalents (FTEs) in the year 2018. 

By December 2022, as offices remained closed and remote work blossomed, that had grown to 2,324 consultancy contracts and 874 FTEs.  The number of contracts continued to grow, post-pandemic. In 2023, HQ issued 2,438 consultancy contracts for 1,025 FTEs. Globally, it was a record  6,311 contracts for 2,398 FTEs.

Although the DG’s report to the EB in cites a decline in consultancy contracts in comparison with July 2023, which represented a seven year peak, in fact the number of FTE’s as of July 2024, numbering 2448, was still more than total FTEs as of December 2023, which numbered 2398.  

Source: WHO Workforce data – 2016-2024. Note: Data in table is for end year, except for 2024. FTE refers to the number of full-time equivalent personnel engaged. The higher the ratio of contracts:FTE, the higher the managerial and admin transaction costs.

But consultancies are only part of WHO’s evolving gig economy. There are also Special Services Agreements for nationals or residents of the host countries where WHO regional offices are located.  These too, have increased by 56% from 3584 in 2016 to 5,606 in 2023, and to 4,811 in just the first seven months of 2024. A striking exception is Europe, whose strict work laws likely make such contracts impractical. 

Source: WHO Workforce data – 2016-2024. Note: Insofar as no FTE is noted, it is assumed that most SSAs are full-time positions.

Finally there are product-related contracts, Agreements for Performance of Work (APW) that are typically outsourced to companies for graphic design, printing and web-related services. It is the only non-staff category to have remained relatively stable since 2017 – with contracts worth 517 FTEs in 2024, as compared to 480 FTEs seven years earlier. 

This can partly be explained by a decline in the use of APWs at HQ to comply with strict Swiss employment rules excluding individuals who were not legally self-employed. The result: gig workers who didn’t have the right paperwork became “consultants” instead.   

If indeed most SSAs are indeed full-time positions – something undefined by the WHO reporting –  then there were an estimated 7,579 FTEs in non-staff positions as of July 2024, as compared to 3,798 as of July 2017.

Notes: Includes FTEs for APWs and Consultants; Assumes each SSA is a FTE because no equivalent is provided in HR reports.

Pragmatic and justified – sometimes

In many cases, short-term non-staff contracts are pragmatic and justified. They are an avenue for flexible, cost-effective hires for short-term projects and events in a world of unpredictable health crises. The DG’s HR update presented at the EB in February  hints at this with its references to “adapting to evolving needs.”  

Moreover, outsourcing expertise for localized health challenges can be vital to meet a series of  health emergencies that have wracked regions such as Africa  without bloating permanent payrolls.  

But the consultancy boom also raises questions in today’s current crisis. 

As WHO freezes hiring for rank-and-file staff positions in an effort to peel back costs, there’s a heightened risk that the organization will be forced to fall back even more on cheap and short-term consultants who are available locally or can work remotely. 

Long term, consultants replacing regular staff will drain the organization of skills, experience and institutional knowledge and act as a bandaid rather than a sustainable model for funding woes. 

In addition, the managerial and administrative costs of managing 6,311 contracts for just 1,253 FTE consultants, to take one category of work, are huge. That works out to nearly five contracts a year per full time position. 

Finally, how geographically balanced are consultancies filled at headquarters,  where young Europeans with Swiss or EU visas can easily fill positions, but Africans, Asians and Americans cannot compete at all? 

As UN Secretary General Antonio Guterres stated in an open letter to member states on 7 February: while “hiring restrictions are inevitable because personnel costs constitute the largest part of the budget. Unfortunately, hiring restrictions undermine gender and geographic representation goals and weaken the effectiveness of our operations.”

Gig economy and expanding staff

Sources: Tables 1 and 20 – July 2017 and July 2024 WHO HR Update – Workforce Data.

But for now, the trend is clear: WHO has been leaning hard into the gig economy over the past few years – even as total staff increased by 17%, from 8,029 in July 2017 to 9,473 as of July 2024.  When non-staff contracts are included, the total workforce increased by a whopping 46% from around since 2017 – from roughly 11,800 to  17,220 staff and non-staff in 2024.

Sources: Tables 1 and 20 – July 2017 and July 2024 WHO HR data. July, 2017 is used as the benchmark to make a comparable mid-year account with 2024 of consultancies – although more new contracts may be signed until early December.

Naturally, increased staff has also meant increased costs – rising faster at the Geneva Headquarters where post adjustment and certain other allowances are comparatively higher.  As of 2024, costs at WHO’s Geneva office for professionals and senior managers, including post adjustments and other benefits, had increased by roughly 50% in comparison to 2017. 

Sources: WHO bi-annual HR reports, and UN salary scales, in comparison to proportion of costs attributable to entitlements and benefits.  Note: Costs of P6 positions, while comparable to D1, are included in the P- category, not D category.

Costs continued to grow between 2023-24, even when average staff and contract numbers flattened out because the most expensive layers of professional staff had increased faster than other categories and P staff also receive in-grade advances every year or two, increasing their costs, particularly in the higher ranks.

At the February EB, China asked why, if “the number of individual staff has remained relatively stable and that the number of non-staff personnel, consultants and special service agreements has been significantly reduced, staff costs have risen from 36% to 47% over the past year.” 

In fact, between 2023 and 2024, the total P, D and senior staff, the most expensive pay categories by far, increased by about 4% from 3,787 people in 2023 to 3,923. In contrast, staff at all levels – national, administration and professional – increased by only about 2.2% from 9,261 to 9,473 staff. 

Low and mid-rank professional staff are most vulnerable 

Along with reducing new, younger staff hires, the risk is that the austerity measures will boomerang on existing professional staff in the P1-3 grades, the organization’s “worker bees”, through hiring freezes and contract expiration. 

The default option will be to leave most of the highest-paid and highest-ranking staff in place as they are the most difficult to trim, both politically and legally,  while shedding rank and file at the bottom of the pyramid.

Only about half of professional staff in the low-mid (P1-3) have “long-term” contracts of a year or more that would protect them from immediate dismissal. An increasing number of professional staff in Geneva’s headquarters have been engaged on rolling contracts of 60 days or less, which may include health insurance, but no vacation days or other benefits.  

Inputs: Human Resources Update, Workforce Data, 31 July, 2024: Tables 3C and Table 3B. Note: “Long-term contracts” includes fixed term contracts of 1-2 years, or continuing contracts that have no termination date.

In comparison, over 90% of D1-2s have long term contracts – including many on continuing contracts that are not term-limited at all.  Termination of such contracts is a complex process, involving either payouts or relocation to other jobs of equivalent status. 

The comparison also highlights the historic paucity of staff in the P1-2 ranks – inexpensive, entry level positions that young, talented professionals from around the world would be keen to fill.  

In 2024, there were only 18 P1 staff in the entire organization and only 287 P2s, or less than 8% of the entire workforce.   Even in 2017, such positions were often filled by APWs or other short-term contractors who were easier to hire, didn’t require work visas, and didn’t receive benefits either. 

How to prioritizing without knowing the real costs?

In a time of belt-tightening, the inevitable question arises: who may be released and who may be retained? 

The WHO letter to all staff aged 55 and older, offering them early retirement with four months of pay was hailed as an effort to pare back in its more senior ranks.

The problem is that such offers target people by age, rather than by their real cost to the organization – not to mention productivity or lack thereof. 

Those in the highest paying ranks of the organization with the fewest qualifications and motivation would also be the least likely to bite at early retirement offers because the WHO salary and benefits are simply too good compared to what they could earn elsewhere. 

Along with freezing staff recruitment, reducing contract renewals to 1 year, and offering early retirement, in his email to staff on Monday, WHO’s Thomas said non-staff costs such as procurement and travel were being rolled back.

“Our response is built around three key pillars: resource mobilization and continued engagement, cost containment and efficiencies, and prioritisation,” he said in the message seen by Health Policy Watch, stressing that “prioritization”  is the operative word to “ensure that every resource is direted toward the most pressing priorities, while preserving WHO’s ability to make an lasting impact.”

The rub is this. Without more transparent disclosure of data, and discussion about the real cost of staff positions at different ranks and locales – including the number of consultants and their pay; and the optimal balance of high-ranking and rank-and-file staff – the big risk is that austerity will only make the organization more top-heavy and more inefficient. 

Unless hard data on staff costs, not only positions, is shared transparently, member states, donors and staff will be unable to rationally assess and respond to any of the cost containment moves that WHO makes – against strategic priorities, budget goals and ceilings. 

Turning crisis into opportunity: recalibrating the pyramid 

Suggestions coming from staff focus on looking at the highest-level ranks of the organization first rather than last – and taking the much-vaunted “transformation” initiated by Tedros in 2017, a step further, with measures such as:  

  • Eliminate D2 positions altogether – reverting all Directors positions to D1s;
  • ⁠Reduce directors at headquarters, the most costly locations. (there are 46 D2s there now) and ship them off to the regions or country offices – some might choose to resign instead;. 
  • Create an even slimmer headquarters that was envisioned by Tedros or his predecessors with a HQ to Regional office to Country office professional staff ratios of 15:15:70 – as compared to the nearly 30% proportion that Geneva’s headquarters has currently, including both professional staff and consultants. 

 ⁠“The problem is that there is no clear HR strategy,” one senior staff member told us.  “Even with the transformation, it’s not very clear what was done. Member states are asking.” 

Another WHO scientist told Health Policy Watch:  “If the organization is serious about cost reduction we should invert our pyramid to have a lean and mean HQ and strengthen our country presence – which is the mantra for an organization that’s looking for country impact.

“Even when some programmes or tasks need to be maintained near headquarters, they can be  moved to Budapest, Copenhagen, Istanbul etc.

“This was also supposed to be the focus of the Director General’s transformation initiative, and could leave him with a lasting legacy.”

________________________

Acknowledgments and disclaimers: Former and existing WHO staff, who requested anonymity, made significant contributions to the data analysis and review.  From 2004 until 2018, Elaine Ruth Fletcher served as a P-3 and P-4 staff member at WHO, managing a budget of over $400,000 in the final years of her career there – as well as a team of short-term consultants.  

Updated Sunday 30 March with the details of the latest email by WHO Director General Tedros Adhanom Ghebreyesus to all WHO staff. Updated, Tuesday 11 March to include details of the latest email from WHO to staff and response from WHO spokeswoman Margaret Harris.  Data correction on consultants – with number of contracts numbering 4128 and FTEs numbering 2448 as of 31 July 2024. 

Image Credits: WHO/L.Mackenzie, WHO Human Resources Update, Workforce data, 31 July 2024., U.S. Mission Geneva/ Eric Bridiers, WHO HR Update, 31 July 2024, Appendix 1. WHO Staff Regulations and Staff Rules, January 2024, WHO , Source: Table 3B HR update 31 July 2024, WHO HR and EB records, 2023-2024, Amendments to staff regulations and staff rules, EB 156, Item 27.6, You Tube/Reuters, WHO HR Updates , 2017 and 2024 WHO HR Data , WHO HR Update, Workforce Data, as of 31 July 2024.

Contraceptives reproductive health Africa panel
Panellists during the session on ‘Reclaiming Control: Let’s Talk About Sexual and Reproductive Health and Rights’

Access to contraception must be lowered to allow teenage girls to make informed decisions about their bodies, relationships, and futures, say key African health stakeholders – including sexual and reproductive health workers and advocates. But are policymakers ready to adopt this change – particularly as the debate over sexual and reproductive health rights becomes ever more fraught and polarized?

At the just-concluded Africa Health Agenda International Conference (AHAIC), experts highlighted a troubling contradiction: while contraceptives are widely available across the continent, teenage girls under 18 often cannot access them without parental consent—consent that is not commonly sought, and when it is, frequently denied.

Easier to get an abortion than contraception 

Contraceptives African teenage pregnancy
Dr Samukeliso Dube, Executive Director of Family Planning 2030.

Rwanda is one of the countries grappling with this issue. According to Dr Clarisse Mutimukeye, Rwanda Chapter Lead for Women in Global Health and Executive Director of Medical Doctors for Choice, laws governing contraceptive access are often more restrictive than those regulating abortion.

“In Rwanda, the law allows pregnancy termination up to 22 weeks if the person seeking the abortion is under 18, following an application by their legal representative. But to access contraception, girls under 18 still need parental consent,” she explained.

“You can imagine if a girl falls pregnant at 15—she is allowed to seek a safe abortion, but she cannot access contraception beforehand. This is a problem.”

This ‘problem’, led to over 39,000 teenage pregnancies in the country in 2022, according to Rwanda’s census. Without access to contraceptives, many girls resort to unregulated and unsafe options, putting their health at serious risk. 

Alternatively, teenage girls opting to become mothers before they have finished their education or training, risk a lifetime of poverty and dependency on family members and others. 

Recognising the urgent need for reform, the Rwandan parliament is now considering a new bill that would allow girls as young as 15 to access contraception without requiring parental consent.

Teenage mothers getting pregnant ‘again and again’

Although a decline in adolescent birth rates has been observed globally, sub-Saharan Africa continues to have twice the global average.

But Rwanda is not alone in facing this challenge. Many African countries, including Kenya, have similar restrictions. Ritah Anindo Obonyo, Executive Director of Community Voices Network in Kenya, said policies drive young girls toward dangerous alternatives.

“Teenage girls are unable to access safe contraception, so they’re using emergency contraception as a long-term birth control method, which is not recommended,” she explained. “They are also using ‘Sofia’ or ‘China pills’, which are sold in backstreets and contain unsafe components.”

The lack of safe contraceptive options has led to a troubling rise in repeat pregnancies amongst teenage mothers, Anindo observed.

“With our organisation, we’re seeing a new trend—teen mothers are getting pregnant again and again. You can imagine what this means for their lives.”

Teenage pregrancy in africa contraceptives
Teenage pregnancy has a prevalence rate of over 25% in 24 African countries, a rate that reaches as high as 48% in Niger and 44% in Chad.

The Fight for Autonomy

For many advocates, the debate over contraception is about more than just access—it is about control over young people’s bodies and futures.

Patriarchal systems continue to deny young people autonomy over their reproductive choices, said Dr Samukeliso Dube, Executive Director of Family Planning 2030.

“I think patriarchy is exhausting because it manifests in so many different forms. It’s always about control—who can I control at any given time? Let’s control who has access, when they have access, and how they have access.”

“Everyone has the right to decide if, when, how many, and with whom they want children. That is a fundamental basic right,” she said.

Panelists African Health
BBC’s Namulanta Kombo(left), in conversation with Dorothy Nyong’o, Managing Trustee of the Africa Cancer Foundation and Dr Meggie Mwoka, Innovations Manager, Amref Health Africa.

With Africa facing dwindling health resources due to aid cuts, experts argue that expanding access to contraception and comprehensive sexual and reproductive health education is one of the most effective ways to both ensure girls’ and womens’ basic reproductive health rights as well as optimising existing funds.

Professor Charles Okeahalam, Chairman of Amref Health Africa’s International Board of Directors, stressed the economic and social benefits of investing in women’s reproductive health and education.

“If we educate girls and give them more sexual and reproductive health rights, population growth would slow, and with a lower population growth rate, the demand for [healthcare] resources would also decrease,” he said. “But even beyond that, better-educated mothers and empowered women are more capable of caring for their children. Investing in female education—particularly in reproductive health—is an essential part of preventive care and resource management. These are the people most directly involved in providing care within families and communities.”

30 Years After Beijing, Women’s Voices Are Still Being Ignored

This year marks the 30th anniversary of the Beijing Declaration and Platform for Action, a landmark commitment by governments to advance gender equality and women’s rights. Yet, female health leaders at AHAIC noted that many of the issues raised in Beijing in 1995 remain unresolved.

Dorothy Nyong’o, Managing Trustee of the Africa Cancer Foundation, reflected on the progress—or lack thereof—since attending the historic conference.

“I was present at the meeting in Beijing, and what is intriguing today is that 30 years later, the more things have changed, the more they have remained the same,” she said. “It’s unfortunate that despite some progress, when I attend the Commission on the Status of Women (CSW) year in and year out, we are still discussing the same issues we raised in Beijing.”

Image Credits: Edith Magak/HPW, Edith Magak/ HPW, African Union 2022.

The withdrawal of the United States foreign aid has disrupted health programmes across the world, including those curbing malaria (above).

When America catches a cold, the world sneezes. Thus, the US withdrawal from the World Health Organisation (WHO), along with the gutting of USAID, PEPFAR and other aid programmes, has put the entire global health community in disarray. 

Across the world, healthcare services for some of the most vulnerable people have been shut down. Public health programmes are being defunded.

This global health crisis is part of a wider attack by the world’s most powerful nation on multilateralism and the hopes and values embedded in the United Nations Charter. Among other things, the US has blown a hole in the Paris climate agreement, snubbed international efforts to ensure that artificial intelligence develops responsibly and sustainably, and reinstated the Global Gag Rule.

This rupture in the international order also marks the end of US-backed neo-liberal globalization and the ascent of explicit US nationalism. Concurrently, the US itself appears to be lurching further towards autocratic and plutocratic rule, while the social foundations of a rights-based universalism and the rational and scientific foundations for informed, inclusive and democratic discourse erode under pressure from cynicism, fear and mistrust grown over decades of neoliberalism, and now amplified by a form of populism that thrives on misinformation and social division.  

But anti-global sentiment, populism and attacks on international solidarity and rational discourse are not confined to the US. Other nations are cutting their aid budgets and threatening to withdraw support from the UN. 

It looks likely that official development assistance (ODA) contributions will be pegged to the 2023 Organisation for Economic Co-operation and Development (OECD) average of about 0.37% of GDP rather than the 0.7% target set in 1970, effectively slashing development assistance by more than half. 

At the same time, civic space and freedoms have been shrinking in many other countries, as the digital revolution risks ushering in new and potent forms of social control and oppression; and ethnic, racial and religious enmity, and a backlash against the rights and freedoms of girls and women appear to be growing in many parts of the world.

Ambitious response

These are challenging times for those working in global health where equity, universal human rights, peace and international cooperation are foundational building blocks. How then should we respond? 

Some will focus on damage-limitation and preserving as much as possible the complex of global health structures, initiatives and programmes that mushroomed in the so-called golden age of global health of the 2000s. 

But a much braver, and more ambitious and comprehensive response is needed.

First, we must reaffirm the moral and political foundations of ‘health for all’. In doing so, we must recognize the error of those who dismissed the bold agenda of the 1978 Alma Ata Declaration and sought instead to narrow the scope of global health to technocratic, bio-clinical and apolitical approaches. 

In parallel, we must avoid the use of technological solutions to disease and premature mortality as an excuse for neglecting the social determinants of health. And we must recognize the limits of aid or charity to health improvement and instead bind global health to social, economic and political justice and those social movements striving for universal rights and freedoms, gender equity and socio-economic fairness.

Second, we must get out of our silo and engage with economic policy and governance. This includes understanding the history of the past 50 years of neoliberal globalization that has resulted in a highly destructive, hyper-financialized and neocolonial form of capitalism that has, among other things, driven humanity towards ecological catastrophe and produced astonishing and dangerous levels of inequality. 

Incredibly, in 2024, 2,769 individuals (predominantly men in the global North) command a combined wealth of $15 trillion while billions of people remain mired in poverty.

One target of global health professionals should be the tax abuse by transnational corporations and ultra-wealthy individuals, facilitated by tax havens and a banking system with the help of prestigious legal, accounting and consultancy firms

This is a social pathology that is every bit as lethal as any imagined viral pandemic. Conversely, ending tax abuse and accelerating the current momentum behind a universal wealth tax would generate billions of dollars for public goods and services, reduce corruption, improve economic productivity, and re-democratise society. Current UN tax treaty negotiations provide an opportunity to establish a meaningful International Tax Convention.

New modalities of aid

Third, in reacting to the collapse of foreign aid, we must acknowledge and correct the deficiencies, fragmentation and inefficiency of the entire donor-driven system of aid. Although much foreign aid has been used to fund essential services for hundreds of millions of people in poor countries, it has too often served the economic and foreign policy interests of donor countries and their corporations. 

While development finance from wealthy countries is still needed, now is the time to adopt new modalities of aid based on the principles of shared funding, governance and delivery as proposed by the Global Public Investment initiative. 

Now is also the time to convert the multiplicity of vertical, narrow and selective global health agencies and programmes into a more coherent and socially accountable model of development assistance that builds from the bottom up rather than imposes from the top down.

Fourth, we must not allow the current crisis in health financing to further expand the incursion of private finance without first committing to raising levels of public expenditure by ending illicit financial flows, tax abuse and unjust debt burdens, and ensuring that the use of private finance for health and development is done appropriately and with effective public-interest regulation. 

Too often, public private finance initiatives are designed poorly  and act as a means by which public money subsidises excessive and abusive profiteering.

Rally around WHO

The WHO flag flying above its headquarters in Geneva.

Finally, we must rally around the World Health Organization (WHO) and its dual role as an inter-governmental organization with the mandate to coordinate and facilitate global and cross-border health cooperation (including through the making of treaties), and a specialised agency that produces scientific and technical norms, standards and guidance. 

We must ask our governments to reaffirm the core normative mandate of WHO but in doing so, we must help the general public understand how WHO will always be compromised by national and international politics (as we are seeing now), as well as by powerful private actors with a vested interest in weakening WHO’s full public health mandate. 

Crucially, we must ensure that WHO’s budget deficit is not an excuse for even more dependence on unaccountable and non-transparent private financing, or for core responsibilities being ceded to private institutions or multi-stakeholder forums.

It has become clichéd to speak of crises as also being opportunities. But global health is truly at a crossroads, and one that provides an opportunity to construct a new vision that seeks not just the reduction of disease and illness but also the dismantling of ecologically destructive and unjust political and economic systems, as well as the reassertion of universal rights and freedoms. 

But for this to happen we must commit to principles of good global health governance and be willing to combine our professional duties with our civic responsibilities to uphold democratic and public-interest institutions, and to strengthen the voice and efforts of communities and civil society organizations on the ground.

David McCoy, Johanna Riha, Claudia Lopes, Remco van de Pas are all current Policy and Research Leads at the United Nations University – International Institute for Global Health (UNU-IIGH). Unni Karunakara was until recently the interim Director of UNU-IIGH.  Collectively they work across a range of policy issues including gendered inequalities in health, digital health governance and security, climate justice and health, and systems of power and accountability in global health.

 

Image Credits: WHO, US Mission in Geneva / Eric Bridiers via Flickr.

Dr Ngashi Ngongo, Africa CDC led on mpox.

Only 17% of suspected mpox tests in the the Democratic Republic of Congo (DRC) had been tested in the past week – a drop of almost 10%, Dr Ngashi Ngongo, the Africa Centres for Disease Control and Prevention (Africa CDC) lead on mpox, told a media briefing on Thursday.

Only seven of the DRC’s 26 provinces in  are reporting on mpox cases, and efforts to address the epidemic are being undermined by conflict and the withdrawal of aid from the United States, he added.

“With the US aid freeze, there is no money for the transportation of specimens,” said Ngongo.

However, Africa CDC is assisting the country to decentralise its laboratory services to make testing available close to outbreaks. The country’s laboratories have been expanded from two to 21 between last July and February.

“But the target was to reach 56 laboratories to be able to get all the health zones to have laboratories to then eliminate the need to transport samples,” said Ngongo, adding that the ongoing conflict, particularly in eastern DRC, had affected plans.

Some two million people are displaced in the DRC due to conflict – most recently in the east, and health players have requested a humanitarian corridor to restore health services to North and South Kivu which have been taken over by M23 rebels.

In better news, some 300,000 people have been vaccinated against mpox over the past 10 days in the DRC capital of Kinshasa – over half the target. The vaccination uptake has increased significantly since health authorities changed its focus from contacts and key populations to anyone living in geographic hotspots, said Ngashi.

However, the new variant of mpox Clade 1A has also been identified in Kinshasa. The variant now has one of the same genes as Clade 1B that is linked to higher transmissibility, and this could also increase the infectiousness of Clade 1A.

Ebola in Uganda

Five cases of Ebola – three confirmed and two probable – have been reported in Uganda over the past week.

The new outbreak was first identified in a four-year-old child, and has no apparent link to the outbreak involving nine people three weeks’ ago. However, genomic testing has established that it is the same strain.

In that outbreak, a nurse was thought to be the index case but as she lived in a city and had no contact Ebola-carrying animals, the usual source of outbreaks, investigations are ongoing to see whether there is another index case, said Ngongo.

In Pakistan, a healthcare worker listens to a child’s lungs for signs of pulmonary tuberculosis.

Years of progress against tuberculosis, the world’s most deadliest infectious disease are being derailed by the abrupt funding cuts by the United States to the sector, according to a survey of 180 affected organisations released late Wednesday.

As many as a quarter of the 180 survey respondents from 31 countries have had to close in the past few weeks, and 25% have cut back on TB treatment for those already on medication – massively upping the risk of a global explosion of drug-resistant TB.

“Countless people having TB, including its resistant forms, face the imminent threat of losing access to essential medications – further risking an increase in transmission and drug resistance development of mammoth proportions,” according to the TB Community Coordination Hub, which compiled the survey.

Virtually all the projects surveyed had received US “stop work” orders and half reported that their ability to deliver TB services has been “severely” impacted by the orders. 

Impact of US ‘stop work’ orders on TB projects surveyed

Over three-quarters (78%) have laid off staff, and community health workers (CHW) have borne the brunt of the layoffs. Half the organisations reported having to lay off their entire community-based staff.

CHW “ensure timely diagnosis and treatment for people with TB and drug-resistant TB”, according to the hub.

As a result of the collapse of funding for CHW, almost half  the projects (46%) have stopped TB screening and outreach and 29% are unable to start people with TB on treatment.

USAID has been the largest bilateral donor in the TB sector, having invested over $4.7 billion since 2000, saving over 79 million lives. 

‘We won’t walk away without a fight’

“[We] strongly condemn this callous, abrupt and totally one-sided act that is unprecedented, and calls upon the US Administration to take immediate measures to restore funding and support projects globally that are crucial to contain and prevent a resurgence of this deadly disease”, the hub added. 

The hub also calls on all countries, global TB leadership and donor organisations to “take urgent measures to gear up alternate funding to enable uninterrupted TB treatment and care to those in need, while upholding commitments to End TB as a global health security priority and a crucial indicator of Sustainable Development Goal 3”.

“Our survey reveals the devastating impact of the US funding cuts on civil society, technical organisations and TB community networks at local and national levels,” said Dr Robyn Waite, part of the hub’s secretariat.

“Now, with termination contracts in place, our findings are but a glimmer of the escalating crisis. As TB activists and advocates, we are shocked and struggling to deal with the fallout. But let’s be clear – we will not walk away without a fight.”

No support for ‘most vulnerable’

In Thailand, a patient with multi-drug resistant TB receives his daily treatment.

Atul Shengde, the National Youth Coordinator of the Global Coalition of TB Advocates in India, said that the cuts meant that his organisation “can no longer reach the most vulnerable – children, women, sex workers, injecting drug users, transgender people, and migrant workers”.

“Previously, when patients struggled with the harsh side effects of TB medication, we were there to support them and keep them on treatment. Now, that critical support system is gone. The voices that once guided people through TB care have been silenced, and without them, I fear we will see TB spread even faster,” warned Shengde.

Impact of US stop work orders on projects surveyed

“In southern African countries, we’re hearing devastating stories: people avoiding TB centers out of stigma attached to lining up in queues, a woman forced to share half of her medication with the husband to ensure continuation, a young person skipping doses to stretch limited supplies, and a patient receiving near-expired drugs,” said Bruce Tushabe of the AIDS and Rights Alliance for Southern Africa (ARASA).

“In the absence of community healthcare workers and other technical staff, we will continue to hear these gruesome stories of stigma, treatment disruptions, and a rise in multi-drug resistant tuberculosis.”

Timur Abdullaev, a board member of TBpeople Global, said that the US funds cut had caught the TB community off guard and also revealed that “some essential elements of national TB programs appeared to be run fully by USAID”. 

“Unfortunately, we see exactly the same overly confident reliance on the Global Fund,” warned Abdullaev. 

“Protecting the lives of a country’s citizens is the responsibility of the country, not that of external donors or technical partners. Not being prepared for the loss of an external donor – even as large as USAID – and the failure to respond quickly to the resulting crisis is simply criminal.”

‘Devastating impact’

Dr Tereza Kasaeva, WHO’s Global TB Programme director,

The World Health Organization (WHO) said on Wednesday that the 2025 US funding cuts will have “a devastating impact on TB programmes, particularly in low and middle-income countries that rely heavily on international aid, given the U.S. has been the largest bilateral donor”. 

The US has provided approximately $200–$250 million annually in bilateral funding for the TB response at country level, around a -quarter of international donor funding for TB, according to the WHO.

“These cuts put 18 of the highest-burden countries at risk, as they depended on 89% of the expected U.S. funding for TB care. The African region is hardest hit by the funding disruptions, followed by the South-East Asian and Western Pacific regions.”

Dr Tereza Kasaeva, WHO’s Director of the Global Programme on TB and Lung Health, said that “any disruption to TB services – whether financial, political, or operational – can have devastating and often fatal consequences for millions worldwide”.

This was proven during the COVID-19 pandemic, she added,  when “service interruptions led to over 700,000 excess deaths from TB between 2020 and 2023, exacerbated by inadequate social protection measures”.

Image Credits: USAID, Southern Africa/Flickr, Stop TB Partnership, USAID Asia.

USAID staff offload emergency supplies.

The United States Supreme Court has declined to intervene in the Trump administration’s freeze on foreign aid, referring the matter back to a District Court Judge who had earlier issued a temporary restraining order against the freeze.

Judge Amir Ali issued the order on 13 February ordering the US administration to resume payments for work already done on Congress-approved contracts that were in place before Trump took office. 

Ali ruled that Trump and his officials were “temporarily enjoined” from “suspending, pausing, or otherwise preventing the obligation or disbursement of appropriated foreign-assistance funds in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025”.

He also prevented them from “issuing, implementing, enforcing, or otherwise giving effect to terminations, suspensions, or stop-work orders” related to these financial awards.

However, hours before the order was due to go into effect on 26 February, Trump’s legal team turned to the Supreme Court, claiming that Ali lacked the authority to make such a ruling.

Chief Justice John Roberts then issued an administrative stay of the order to enable the Supreme Court to consider the matter. 

Wednesday’s Supreme Court ruling – with five judges in favour and four against – simply directs Ali to “clarify what obligations the government must fulfill to ensure compliance with the temporary restraining order, with due regard for the feasibility of any compliance timelines”.

Ali’s ruling was made in response to court action by three civil society organisations – the AIDS Vaccine Advocacy Coalition (AVAC), Journalism Development Network and the Global Health Council – challenging Trump’s Executive Order (14169), which immediately stopped all congressionally appropriated foreign assistance funding pending future review.

Return to court

The plaintiffs return to court on Thursday (6 March) ​​where they will argue for a temporary injunction against the aid freeze.

A spokesperson on behalf of the plaintiffs told Health Policy Watch that they are encouraged by the Supreme Court’s ruling today.
“But each passing day that we are not compensated for work already performed causes additional harm to American workers and suppliers across the country,” added the spokesperson.
“Thousands of jobs all over the US have already been lost, with more likely to come. Hundreds of businesses – primarily small businesses, the backbone of our economy – face an existential crisis and the possibility of financial ruin. Meanwhile, every passing second denies millions around the world the essential care they desperately need, putting countless lives at even greater risk.”

The plaintiffs’ lead counsel, Lauren Bateman, an attorney with Public Citizen Litigation Group, stated on Wednesday that the Supreme Court ruling “confirms that the administration cannot ignore the law. To stop needless suffering and death, the government must now comply with the order issued three weeks ago to lift its unlawful termination of federal assistance.”

During the earlier court hearing, the plaintiffs detailed some of the effects of the freeze on foreign aid dispensed by the US Agency for International Development (USAID) and the State Department.

It has disrupted critical health programmes including maternal and child health programs; infectious disease prevention including against malaria and HIV, and clinical trials.

Plaintiffs were also forced to lay off staff in response to the freeze.

In its defence, Trump’s legal team claimed that life-saving health programmes had been given waivers. But this is no longer the case as the majority of USAID has been dismantled and life-saving projects were issued with permanent termination letters last week.

AVAC executive director Mitchell Warren

AVAC executive director Mitchell Warren appealed for support for the case: “These are immensely challenging times for all of us, and it is easy to be paralysed, overwhelmed and depressed. But we’ve all come too far for that to be the new normal. Lives, economies and democracies depend on our collective ability to stand up and fight back.”

Earlier, Warren described the funding freeze as harmful to global health and security: “In the name of economic efficiency, they are destabilizing public health, diplomatic relationships, communities, and economies.”

Devastating setback for tuberculosis 

The World Health Organization (WHO) said on Wednesday that the 2025 US funding cuts will have “a devastating impact on TB programmes, particularly in low and middle-income countries that rely heavily on international aid, given the U.S. has been the largest bilateral donor”. 

The US has provided approximately $200–$250 million annually in bilateral funding for the TB response at country level, approximately one-quarter of international donor funding for TB, according to the WHO.

“These cuts put 18 of the highest-burden countries at risk, as they depended on 89% of the expected U.S. funding for TB care. The African region is hardest hit by the funding disruptions, followed by the South-East Asian and Western Pacific regions.”

Dr Tereza Kasaeva, WHO’s Director of Global Programme on TB and Lung Healt, said that “any disruption to TB services – whether financial, political, or operational – can have devastating and often fatal consequences for millions worldwide”.

This was proven during the COVID-19 pandemic, she added,  when “service interruptions led to over 700,000 excess deaths from TB between 2020 and 2023, exacerbated by inadequate social protection measures”. 

Image Credits: USAID Press Office.

Robert F Kennedy Jr, Trump’s pick for US Health Secretary.

Amid the worst measles outbreak in the United States in a decade, vaccine sceptic Robert F Kennedy Jr, the Trump administration’s Health and Human Services (HHS) Secretary, has affirmed that vaccines protect children.

“Vaccines not only protect individual children from measles, but also contribute to community immunity, protecting those who are unable to be vaccinated due to medical reasons,” Kennedy wrote in an opinion piece published by Fox News on Monday.

He declared that “the decision to vaccinate is a personal one” rather than advising parents to ensure that their children are vaccinated against measles. 

He also asserted that “good nutrition remains a best defense against most chronic and infectious illnesses”.

The Texas Department of State Health Services has confirmed 146 measles cases since late January and one death of an unvaccinated child, the first measles-related death of a US child in over a decade. Seventy nine of the confirmed cases were unvaccinated while the vaccine status of 62 others is unknown.

“Prior to the introduction of the vaccine in the 1960s, virtually every child in the United States contracted measles. For example, in the United States, from 1953 to 1962, on average there were 530,217 confirmed cases and 440 deaths,” wrote Kennedy.

While affirming that HHS would ensure vaccines are “readily accessible for all those who want them”, Kennedy noted that the US Centers for Disease Control and Prevention (CDC) “has recently updated their recommendation supporting administration of vitamin A under the supervision of a physician for those with mild, moderate, and severe infection”.

The CDC noted in a statement last month that “supportive care, including vitamin A administration under the direction of a physician, may be appropriate”.

Vitamin A has been shown to reduce the risk of death from measles by 87% in children younger than two years old, and reduce the length of time the child suffers from diarrhea and fever, according to the Cochrane Review. 

In his first address to HHS staff on 18 February, Kennedy said the he would investigate the childhood vaccine schedule as part of the Make America Healthy Again Commission set up by Trump that Kennedy is chairing.

“Nothing is going to be off limits,” Kennedy said, adding that the commission would investigate the health impacts of pesticides, food additives, microplastics, antidepressants and the electromagnetic waves emitted by cellphones and microwaves.

Last week, the Food and Drug Administration cancelled an advisory committee meeting to discuss the composition of annual flu shots, which then have to be cultured. 

 

Safiya Shuaibu (Nigeria Health Watch), Professor Mamadou Samba, Côte d’Ivoire’s Director General of Public Health and Hygiene, Aminata Wurie (Resilience Action Network Africa) and Roche’s Johnpaul Omollo.

KIGALI, Rwanda – On average, African Health Ministers only have $40 per capita for health expenditure in comparison to $4,000 that ministers in many high-income countries have. 

How the continent can provide the maximum level of healthcare with such limited resources is one of the key questions that delegates to the Sixth Africa Health Agenda International Conference (AHAIC) in Kigali are trying to answer.

There is consensus that aid is no longer a reliable solution in light of overnight funding cuts by the United States, and more incremental cuts from Europe. South-South solidarity and drawing more effectively on domestic resources are emerging as likely solutions.

’“To be honest, we cannot afford healthcare for everyone, but we can afford health, which will reduce our overall healthcare costs,” admitted Amref Health Group CEO, Dr Githinji Gitahi.

Prevention Over Treatment

The first short-term solution to manage the $40 well is by focusing on the basics and prioritizing prevention over treatment.

“The foundation of health is clean water for everyone. It is sanitation for everyone. It is access to nutritious food to reduce the risk of non-communicable diseases. It is a strong emphasis on immunization. If we prioritize these, we will save significantly on future healthcare costs,” Gitahi explained.

More investment in community health workers than expensive medical equipment like PET scans and MRI machines is also prudent.

“Health is built at home – hospitals are there to repair,” he added. “We need to redesign our health systems to make prevention, primary care, and community health the core pillars.”

Increasing the $40

However, even with careful management and efficiency, stakeholders agree that $40 is simply not enough. 

“We need political action now. Within our national budgets, health is not at the forefront. How many countries have actually reached the commitment of allocating 15% of their national budget to health? Just two – South Africa and Cape Verde,” said Aminata Wurie, project manager at Resilience Action Network Africa (RANA).

This year, only one out of the 55 African countries allocated more than 5% of GDP to health while only two out of 55 countries have met the 15% Abuja Declaration commitment.

Last month, Rwandan President Paul Kagame, the African Union’s (AU) Champion on Domestic Health Financing, hosted a High-Level Health Financing Conference in Addis Ababa to discuss alternative domestic sources of health funding.

One of the key outcomes was a mandate for the Africa Centre for Disease Control and Prevention (Africa CDC) to develop a framework for domestic health financing. 

Africa CDC’s Dr Claudia Shilumani confirmed that efforts are already underway: “We are working with the African Medicines Agency and other partners to create a framework that will outline tangible actions governments can take to increase health sector funding. This will be presented to heads of state in the coming months for a decision.”

Meanwhile, Rwanda is already setting an example by integrating existing health financing mechanisms to support long-term goals. 

In response to health system funding cuts, they have reassessed spending priorities to ensure critical programs remain operational. For example, instead of discontinuing workforce training, they have shifted many in-person trainings to online platforms and redirected the funds to essential programs.

Public-private partnerships

More attention is also being paid to public-private partnerships (PPPs) and innovative financing models to ensure the long-term sustainability of health programs.

The pharmaceutical company Roche has committed to significantly increasing access to diagnostic testing across Africa, aiming to conduct over 3.4 billion tests by 2031 and reach more than 500 million people with quality diagnostics.

“Reaching these ambitious goals, especially as Africa’s population continues to grow exponentially, cannot be done alone. Public-private collaboration is key,” said Johnpaul Omollo, Roche’s head of policy and government affairs.

“First, we must ensure decentralisation – this is where localization plays a crucial role. As we expand local production, we must also understand what the market truly needs and identify the most essential products we can manufacture locally,” he added.

South-South vaccine partnerships

Another area where increased partnerships and collaboration will be essential is in vaccine distribution. The US withdrawal from the World Health Organization (WHO) might mean disruptions to vaccine distribution, which could delay availability and hinder efforts to achieve widespread immunity. 

However, vaccine manufacturers like Serum Institute of India (SII) – the biggest generic producer in the world – are stepping up their efforts to ensure the continued supply of life-saving vaccines.

Speaking with Health Policy Watch on the sidelines of the conference, the company highlighted its partnerships with African manufacturers to promote local vaccine production.

“We are collaborating with South Africa’s Aspen and Egypt’s Vacsera to establish fill-and-finish vaccine facilities within the continent,” said Anil Kulkarni, SII’s Senior Manager of International Business and Product Management. “In the coming years, we plan to expand these partnerships to more African countries.”

SII has also committed to maintaining affordable vaccine prices to ensure that African countries can continue to get vaccines despite global funding challenges.

But health experts stress that, for local pharmaceutical production to succeed, it will require a coordinated effort across multiple sectors.

“The success of local production will require all hands-on deck. This means the private sector must be involved in understanding community needs, governments must create an enabling policy environment, and supply chains must be strengthened to ensure medicine accessibility,” said Omollo.

Charles Okeahalam, president of Amref’s Board, described the current challenges facing Africa’s health systems as a wake-up call for the continent.

“If we improve ourselves and systems by just 20%, we could see an 80% improvement in healthcare outcomes. The challenge is real but not as difficult as it might appear.”

Image Credits: Edith Magak.