Countries indicating their wish to speak about the pandemic agreement in Committee A

An enormous list of World Health Organization (WHO) member states, 173 in all, lined up to speak in favour of the pandemic agreement at the World Health Assembly (WHA) on Monday – an extraordinary demonstration of the breadth of support for the document.

By the end yesterday’s meeting of Committee A, member states passed the pandemic agreement resolution by vote not consensus – at the insistence of Slovakia – with 124 in favour, zero objections, and 11 abstentions. The WHA plenary is due to consider the resolution on Tuesday.

But between the cheers were reminders that the talks are not yet done. An annex still needs to be negotiated to establish the mechanisms for a pathogen access and benefit-sharing (PABS) system – the most controversial aspect of the three-year talks.

The PABS system will develop a mechanism for how countries that share information about pathogens with pandemic potential may benefit if pharmaceutical products are developed as a result.

“As a country that has shared its pathogens, often without equitable returns, the PABS system is paramount in rectifying these imbalances and ensuring the realisation of genuine equity and equitable access,” said South African Health Minister Aaron Motsoaledi, speaking for the Africa region in Committee A, where the document was being discussed.

The Africa region sees the target of 20% of pandemic products being reserved for the WHO for distribution to low- and middle-income countries (LMICs) by manufacturers participating in PABS, with at least 10% as a donation, during future pandemics, as a “positive first step”, added Motsoaledi.

Speaker after speaker urged countries to maintain their political commitment to the PABS negotiations and reach an agreement on the annex before next year’s WHA.

Even Hungary, a staunch ally of United States President Donald Trump, welcomed the agreement – and stressed that it did not infringe on countries’ sovereignty, a key claim of disinformation about the pandemic.

Trump distanced the US from the pandemic agreement at the outset of his presidency in January, and many of his MAGA supporters claim it is a “power grab” by the WHO.

Iran and Paraguay said they could not support the current pandemic agreement draft – reserving support until after the PABS negotiations. Meanwhile, Slovakia, which is led by Prime Minister Robert Fico who has spoken out against COVID-19 vaccines, demanded that the agreement be put to a vote during the committee session.

Delegates at WHA’s Committee A after it adopted the pandemic agreeemnt by vote

First ‘One Health’ agreement

Germany said it “would have welcomed stronger provisions, particularly regarding prevention,” but “recognise this agreement as a critical and timely step toward global solidarity and multilateralism”. 

“We urge all member states to engage in the upcoming annex negotiations with the same political will and unity that have brought us this far. Let us continue to invest in international cooperation and global solidarity, not only to protect our citizens, but also to lay the groundwork that future generations can benefit from,” said Germany.

Switzerland, which has sought to protect its pharmaceutical sector during talks, said it supports “a pragmatic, voluntary approach within existing frameworks, that take into account the advice and contributions from experts”. 

The European Union said that the agreement “marks an important accomplishment for global health security and cooperation” and “can bolster country capacities to prevent and prepare for pandemics using the One Health approach”.

Ireland added that “the commitment to [pandemic] prevention through a One Health approach is the first of its kind to recognise the interconnectedness of human, animal and environmental health in our response to emerging health trends”. 

“The establishment of a global supply chain and logistics network and a pathogen access and benefit sharing system will ensure that the response to future health threats will be faster, more effective and more equitable,” it added. 

China said the agreement “will contribute to the fair distribution of health products, relevant technologies and resources to help developing countries enhance their capacities for prevention, preparedness and response” – but that it needed “some follow-up mechanisms, as well as sustained investment and capacity building efforts from all countries” to be effective. 

Kazakhstan said that “this is not just a global legal document. It is our collective response to a future where everybody will be protected, regardless of their economic position or status. We must underscore that the success outcome will be defined not only by its content, but also by its ability the state’s ability to implement it.”

Jamaica, speaking for 22 countries in the Americas and Caribbean (excluding the USA), said the region was ready to do the work to finish the pandemic agreement.

“We remember too vividly the oxygen shortages, the overwhelmed hospitals and healthcare workers, and over seven million lives lost during the COVID-19 pandemic,” said Jamaica. “For the Americas,  this agreement means stronger commitments to regional manufacturing capacity, coordinated surveillance, research and development and transfer of technology, especially for developing countries.”

‘The worst of times’

INB co-chairs Anne-Claire Amprou and Precious Matsoso

Co-chairs of the Intergovernmental Negotiating Body (INB), South Africa’s Precious Matsoso and French Ambassador for Global Health Anne-Claire Amprou, also addressed the session, expressing appreciation to member states for their commitment.

Matsoso reminded the WHA that the special assembly called to establish the INB was convened “at a time when we all wore masks, we practised social distancing, and we had face-to-face meetings that were highly restricted”. 

“It was the worst of times, the season of despair, of tragic losses, immeasurable devastation – all associated with COVID-19,” said Matsoso.

She praised delegates for working through “13 formal rounds of negotiations, many of them extended, producing various iterations of draft pandemic agreement and proposals that have culminated into what we have before us as a consensus draft”.

Amprou, who took over as co-chair from Roland Driece of the Netherlands in July 2024, said that the process involved “three years of dialogue, of compromise, of debates, of sleepless nights, but above all, three years guided by a common conviction that health is a common good”.

“The COVID-19 pandemic was a shock for us all. It was a brutal reminder of the fact that viruses know no borders. No country, however powerful, can address a global health crisis on its own,” said Amprou.

Meanwhile, former co-chair Driece spoke for the Netherlands, expressed his appreciation that the long process had resulted in an agreement.

 

Image Credits: WHO.

The World Health Organization (WHO) is confronting an unprecedented financial crisis.

The World Health Organization (WHO) is confronting an unprecedented financial crisis, with a projected shortfall of $2.5 billion for the 2025–2027 period. In his official remarks to the Programme, Budget and Administration Committee (PBAC) on 14 May 2025, WHO Director-General Dr Tedros Adhanom Ghebreyesus stated that the Organization may be forced to close certain country offices as a cost-saving measure, a signal of just how serious the current funding crisis has become.

In addition, senior WHO officials have also spoken recently about the possibility of moving more key WHO functions and staff from Geneva headquarters to WHO regional or country offices, both as a cost-saving measure and to be more responsive to needs at the grassroots.  So a closer look at WHO’s country office structure is important to evaluate if, how, and in what way such shifts might make sense programmatically as well as economically.

110 WHO country offices – dispersed in countries rich and poor

WHO currently operates 110 country and territorial offices globally. Among these, at least 11 high-income countries (HICs) host full-fledged WHO country or liaison offices, such as Cyprus, Greece, Chile, Uruguay, and Panama, as well as several Eastern European states.

In addition to these formal offices, WHO also maintains technical hubs, project offices, or collaborating centres in other high-income settings, including Denmark, France, Germany, Italy, Japan, South Korea, the United Kingdom, and the United States, in addition to its headquarters in Geneva, Switzerland.

Taken together, this amounts to 17 WHO institutional outposts in HICs, when counting both full-fledged country offices and other technical or liaison presences.

In addition, WHO has 36 offices in upper-middle-income countries (UMICs), such as Argentina, Brazil, China, Indonesia, Mexico, South Africa, and Turkey.

The health body has offices in 57 lower-middle-income countries (LMICs), including India, Bangladesh, Kenya, Nigeria and Nepal, according to publicly available data on WHO’s country presence portal and World Bank income classifications. Many of the latter are large-scale operations that play critical roles in strengthening national health systems.

Traditionally, countries host WHO offices through basic legal agreements, which grant privileges but rarely entail financial responsibilities. In practice, WHO is usually left to fully fund its own in-country presence.

Particularly for high-income countries, this is no longer sustainable in light of the current budget crisis. And even in the case of middle-income countries, an argument can be made for recruiting more national support to WHO country offices, especially when many host governments, some with substantial fiscal capacity, leave large portions of their national health budgets unspent each year.

Hundreds of young tuberculosis advocates participate in a WalkTheTalk rally in Kathmandu to commemorate World TB Day, organized by the National Tuberculosis Control Center, Ministry of Health and Population–Nepal, and WHO Country Office for Nepal.

When Contributions Fund the Contributor: The HIC Paradox

In high-income countries (HICs), the conversation around WHO country office sustainability should begin not with unspent national health budgets, which are closely monitored nationally, but with a sharper look at how much of the country’s assessed contribution to WHO is being consumed by maintaining their own WHO office.

While data on country office costs are not always available, an analysis of selected offices, in comparison with available data, suggests that some HICs hosting WHO country offices are effectively seeing a significant share of their own assessed contributions to WHO consumed in maintaining those offices.

This raises questions about equity and strategic allocation of WHO resources in a time of budget constraints.

For example, this analysis found that of five HIC countries considered, all had country offices financed by the equivalent of half or more of their assessed contributions. In the case of Cyprus and Panama, most of the assessed contribution was spent, effectively, on the country office.

Note: Country office cost figures referenced in this article are conservative estimates based on publicly available data from WHO’s Programme Budget Portal (2024–2025), the Proposed Programme Budget (A76/4), and WHO’s official summary table of Assessed Contributions Payable by Member States and Associate Members in 2024–2025. As WHO does not publish disaggregated office-level expenditures, proportional estimates were calculated using regional budget allocations and typical country office structures, adjusted by office type, regional context, and known staffing patterns. Source: WHO Assessed Contributions (2024–2025); WHO Voluntary Contributions – Specified; WHO Programme Budget Portal.

While exact breakdowns of country office costs remain limited due to confidentiality or aggregated budget reporting, it appears that at least in some countries, a considerable portion of HIC contributions to WHO may be locally absorbed in cases where country offices are maintained – limiting the net benefit to global health of country contributions.

In these contexts, a paradox emerges: a portion of these countries’ assessed contributions, meant to support global health efforts, is effectively recycled to maintain WHO’s presence in their own territory. This raises legitimate questions about cost-efficiency and fairness, particularly when lower-income countries face operational cuts to WHO support that is often vital to their national health systems.

The paradox of unspent national budgets and an underfunded WHO

A similar, though more complex, case can be made for certain upper-middle-income countries (UMICs)—such as Mexico, Brazil, or China—which have increasing fiscal capacity, growing health budgets, and an ability to co-finance WHO presence.

While in the case of MICs, it could be argued that host governments simply can’t afford to support WHO country offices, in light of their own significant public health needs, data from WHO’s Programme Budget Portal and the World Bank provides a somewhat different narrative.

That data reveals that quite a few UMIC and LMIC host governments consistently leave large portions of their health budgets unspent – even while WHO country offices in those same countries face curtailed operations due to the budget crisis.

Unspent National Health Budgets (%) by Country

This paradox becomes even more striking when comparing these unspent funds with WHO’s modest operating budgets in those countries.

Unspent Health Budget vs WHO Country Office Budget by Country

Note: Fiscal calendars and reporting periods vary by country, causing comparability limitations. While the symbolic bar segments in the figure visually represent office costs, they are not to exact scale.

This comparison, based on budget figures, shows that in countries like Brazil, Egypt, and Mexico, WHO’s country office budget accounts for less than 5% of their unspent national health budgets, demonstrating potential fiscal space to fully support WHO’s presence.

Even in more financially strained countries, such as Pakistan or Kenya, WHO’s needs represent only a modest share of what goes unused.

Why a new cost-sharing model is urgent and fair

These findings underscore the importance of considering a new cost-sharing model for WHO’s country office presence – one that looks transparently at costs versus ability to pay and ensures all countries, especially those with fiscal space, contribute to WHO not just as hosts, but as true global stewards.

It also underscores the need, as the WHO Director General has rightly asserted, to reassess whether WHO presence in HICs is cost-efficient and programmatically justified when compared with needs in lower-income settings.

But rather than arbitrary office closures, a transparent assessment should first be undertaken to evaluate:

  • How much each HIC’s country office cost relative to its assessed contribution?
  • What is the critical regional or global health mission of the WHO country offices located in HICs, and could funds spent there be more effectively used to support countries with urgent health capacity gaps?
  • In the case of UMICs, and some LMICs, what is the fiscal space, based on unspent health expenditures or other indicators for exploring cost-sharing arrangements?

Other UN agencies have embraced cost-sharing frameworks

Other UN agencies have already embraced cost-sharing frameworks with host countries.

For example, in 2023, UNICEF required 23 UMIC host countries to cover 30–100% of their office operational costs, including Brazil and Mexico contributing 40% toward local staff salaries. In Turkey, the government financed 40% of UNICEF’s Syrian refugee health response (UNICEF Executive Board Report, 2023).

WHO has lagged behind in this regard. While WHO Member States have committed to incrementally increasing assessed contributions to cover 50% of the organization’s core budget by 2030, progress has been slow. WHO Director-General Dr. Tedros Adhanom Ghebreyesus has publicly stated that “WHO cannot fund itself to perform its mandate,” and has called for sustainable financing.

The time has come for a clear, equal cost-sharing model across all income groups based on the principle that every host country, whether HIC, UMIC, or LMIC, should contribute to WHO’s operating costs, based on its capacity.

High- and upper-middle-income countries should provide full or majority financial support to country offices based there. Lower-middle-income countries may contribute partially, in-kind, or through shared infrastructure support.

Countries that host WHO offices, especially those with significant unspent health funds, should consider that supporting WHO’s presence is not a budgetary burden, but a strategic investment in global and national health security. The alternative is an organization diminished in reach and relevance, unable to operate effectively where it’s needed most.

This model reflects a principle of shared responsibility, while still recognizing economic diversity. Countries like India, South Africa, Thailand, and Mexico, each with substantial national health budgets, regional leadership roles, and established WHO country offices, are well-positioned to illustrate how contributions from LMICs and UMICs can be both feasible and impactful.

No health without sustainable finance

WHO’s country offices have played indispensable roles, from controlling pandemics and delivering vaccines to strengthening primary health systems and guiding policy.

The HPV vaccination campaign reaches Mustang district in the Himalayas, bringing life-saving vaccines to girls aged 10–14.

But the idea that WHO alone should shoulder the financial burden of country offices from its central budget allocations is outdated.

As the 78th World Health Assembly (WHA) opens in May 2025, Member States have an opportunity to consider this issue, the status quo, and potential alternatives, including a capacity-based cost-sharing model.

Any discussion of the division of budget responsibility should also be accompanied by a review of accountability mechanisms. Basic agreements between WHO and host countries must ensure that country offices retain their independence, not always a given even today. WHO country offices should be funded and empowered to act on behalf of the Secretariat, in response to country needs, while maintaining their distinct institutional mandate.

With the pending WHO reorganization and the likely relocation of certain HQ functions to the country or regional level, it’s a timely moment to take a closer look at how country offices are budgeted, governed, and empowered. Their future, as one of WHO’s core pillars of delivery, will depend not only on technical necessity but on whether Member States are willing to back that presence with a financing model grounded in both equity and economic realism.

Pragyan Ghale

Pragyan Ghale is a global health policy consultant, affiliated with the  Public Health and Infectious Diseases Research Center (PHIDReC), Nepal. He holds a master’s degree in Global Health Policy from the London School of Economics and Political Science (LSE). 

Image Credits: WHO Nepal / Facebook post, WHO Assessed Contributions (2024–2025); WHO Voluntary Contributions – Specified; WHO Programme Budget Portal., Photo credit: WHO Nepal / Facebook post.

Dr Tedros addresses the 78th WHA

The World Health Organization (WHO) faces “significant challenges” amid “significant achievements”, characterised by a 21% budget cut alongside the imminent adoption of a pandemic agreement, Director-General Dr Tedros Adhanom Ghebreyesus told the opening of the World Health Assembly on Monday.

Tedros appealed to member states to support its “extremely modest” budget, reduced from $5.3 billion to $4.2 billion for the 2026-2027 biennium as a result of the United States’ withdrawal from the global body.

But this modest amount isn’t even in the bank yet.  It relies on member states agreeing to increase membership fees and receiving more donations via the WHO’s next Investment Round to be held in Geneva on Tuesday.

“Assuming you approve the increased assessed contributions [membership fees], and thanks to the investment round, we’re confident that we have already secured more than $2.6 billion of the funding for the next biennium. That leaves an anticipated budget gap of more than $1.7 billion,” said Tedros.

He added that raising that amount in the current landscape would be a challenge but described the figure – $2.1 billion a year – as “extremely modest” for an organisation “working on the ground in 150 countries with the vast mission and mandate that member states have given us”.

“$2.1 billion is the equivalent of global military expenditure every eight hours,” said Tedros, and “a quarter of what the tobacco industry spends on advertising and promotion every single year”. 

The 78th WHA opened in Geneva on Monday.

Reducing costs has led to a reformulation of the organisation and with significant staff layoffs ahead.

The WHA gave a round of applause to outgoing executive team members Dr Mike Ryan, Dr Samira Asma, Dr Bruce Aylward, Dr Catharina Boehme, Dr Li Ailan and Dr Jerome Salomon, who will be leaving the WHO as part of this process.

“A reduced workforce means a reduced scope of work. The organisation simply cannot do everything member states have asked it to do with the resources available,” he added.

Steep bilateral aid cuts

However, the dismantling of the US Agency for International Development (USAID) and deep cuts to the US President’s Emergency Plan for AIDS Relief (PEPFAR) have strained the finances of many member states, some of which may not be in a position to increase their contributions to WHO.

“Many Ministers have told me that sudden and steep cuts to bilateral aid are causing severe disruption in their countries and imperilling the health of millions of people,” Teros acknowledged.

“In at least 70 countries, patients are missing out on treatments. Health facilities have closed, health workers have lost their jobs, and people face increased out-of-pocket health spending.

“Although this is a challenge, many countries also see this as an opportunity to leave behind an era of aid dependency and accelerate the transition to sustainable self-reliance based on domestic resources.”

But at the same time, several countries were doubling and tripling their defence spending, spending “vast sums protecting themselves against attacks from other countries, but relatively little on protecting themselves from an invisible enemy that can cause far more havoc and damage,” said Tedros, pointing out that COVID-19 killed an estimated 20 million people.

Key achievements

Tedros described the pandemic agreement as a “historic moment” amid “significant opposition”.

In the past year, the WHO coordinated the response to 51 graded emergencies in 89 countries including “outbreaks, natural disasters, conflicts and more”.

It delivered urgently needed specialist medical supplies worth $196 million to 80 countries, supporting countries to address cholera, Marburg and Ebola.

WHO is poised to resume aid to Gaza as soon as Israel lifts its blockade, said Tedros, who  appealed to member states to assist the more than 10,000 patients who need medical evacuation out of Gaza. 

“War is not the solution. Peace and political solutions are the solution,” he stressed.

Tedros stressed that the WHO’s “increased focus on science, data and digital health” is “the future of the organisation”.

“WHO’s normative standard-setting work is its bread and butter, and we have streamlined processes to give member states the highest quality, evidence-based advice as fast as possible,” said Tedros. “Last year, there were 65 million downloads of WHO publications, guidance and other materials.”

Swiss support

Welcoming delegates to Geneva, Swiss Federal Council member Élisabeth Baume-Schneider stressed that her country was committed to supporting the WHO, and would contribute $80 million to the organisation over the next four years.

“The WHO is the only real global platform for cooperation on health matters which has legitimacy, respect and can do the job,” said Schneider.

“It is the only international organisation dealing with health which is run by its member states, and that means shared responsibility… We, as her member states, need to demonstrate that we are ready to reconsider our relationship with the organisation and ensure that we offer our full support.”

WHA president, Dr Teodoro Herbosa of Philippines, urged the assembly to be focused on “unity not unilateralism, solidarity not isolation”.

US and Chinese flags side by side; the US may sit out this year’s World Health Assembly while China sends over 180 delegates to Geneva.

The United States appears set to skip this year’s World Health Assembly at a historic moment when other WHO member states are expected to agree to a Pandemic Agreement, that has been nearly three years in the making.

A provisional list of WHA delegates, published late Sunday night by WHO, included no reference at all to a US delegation.  

China, meanwhile, will be sending what may be their largest-ever contingent to the assembly, which runs from 19-27 May. The list of China’s 180-plus delegates includes not only dozens of senior and mid-level experts from Ministry of Health and Centers for Disease Control, but also leading academics and experts from universities across the country.  

Former WHO Legal Counsel Gian Luca Burci drew the contrast at a WHA preview session Sunday, co-hosted by the Geneva Graduate Institute’s Global Health Centre and the United Nations (UN) Foundation. 

Geneva Graduate Institute legal expert Gian Luca Burci, a former WHO chief legal counsel.

“It would be the first WHA since 1948 without the USA,” he said, if there is no last-minute reversal in position. Meanwhile, the dispatch of such a large Chinese delegation to Geneva is not only a display of global health prowess but “a big logistic achievement,” Burci said, “although apparently China always has a huge delegation because they want to cover everything going on at WHA, including side events.” 

The US Mission did not respond to Health Policy Watch queries about whether it would indeed skip the event. Even after US President Trump’s January announcement that he was withdrawing from WHO, a small US delegation attended WHO’s Executive Board meeting in February, although they remained largely on the sidelines, making only one or two statements. 

Legally, the US withdrawal only becomes effective in January 2026, although the Trump administration has not paid the $260 million in WHO membership fees for 2024-2025 – and there are no signs it intends to do so. 

Seventy-five items on packed agenda

Last year’s 77th session of World Health Assembly in May 2024 in Geneva, Switzerland.

Some 75 agenda items are to be considered by the WHA’s 194 member states during the marathon eight-day session.  They will range from the highly political, and now perennial debates, over Russia’s war in Ukraine, Israel’s war in Gaza, and a proposal to grant Taiwan observer status (over Chinese objections) – to policies and progress reports on dozens of diseases, health risks and the health workforce. The Assembly will also consider new strategies and action plans for climate and health, air pollution, antimicrobial resistance, and mental health, amongst others.  

Along with voting to approve the Pandemic Agreement, expected on Tuesday, member states also need to approve a new 2026-27 budget, which has been trimmed radically since the US, WHO’s largest donor, announced its withdrawal.  

The total budget envelope has been slashed from some $7.4 billion to $6.2 billion, in the wake of the funding crisis that ensued following the US retreat.  

WHO’s “base budget” (excluding $2 billion for polio eradication, health emergencies appeals and special programmes), has been pared from $5.3 to $4.2 billion – a move likely to mean a 20% reduction in WHO’s 9463 staff globally, according to initial WHO estimates. See related story:

WHO Budget Cuts May Slash 30% of Mid-Level Staff, Spare Most Senior Roles

Turn challenge to opportunity  

Against the somber spectre of layoffs and programme cancellations,  WHO Chief Scientist Jeremy Farrar told the Graduate Institute gathering that the global health agency and its supporters need to transform the current crisis at WHO, and in global health institutions more broadly, into an opportunity.

Farrar was recently named to head a new division of Health Promotion, Disease Prevention and Control, in a major WHO leadership shake-up that will see WHO’s 10 programme divisions at headquarters contract to just four, as the organization seeks to streamline and economize.

See related story:

BREAKING – WHO Director General Shakes Up Agency with Brand New Leadership Team

“I look forward to what I think is going to be very tough next six months, 12 months,” Farrar said.  “But organizations have to reform, they have to evolve, and they have to emerge stronger, and that’s not a corporate view. It’s not an institutional view. It’s a personal view.

“Unfortunately, very few organizations do that… But if you can’t do that, the next best time to reform is as soon as the pressure is on, and that is now.”

He said that the reforms underway now at WHO have involved “a very detailed bottom up exercise across the whole organization, countries, regions and headquarters, as to what is the real role of WHO? 

“And now we need to take that and add on to that strategic overlay with [what] member states have to say.”

WHO will emerge in 2026 smaller but better, says Chief Scientist Jeremy Farrar.

Consolidating WHO’s divisions could help eliminate duplication and competition between teams – allowing for a less vertical and more “horizontal” organization, Farrar argued.  

While the corporate pain may be enormous, he urged people to remember that the pain to low-income communities worldwide from abrupt cuts in funding for HIV drugs and testing, not to mention other vital health assistance programmes, has been far greater.  

“We shouldn’t just focus in a complacent way on how this is affecting those of us in WHO or in other UN agencies…. The impact of the country level is very profound. It will be more challenging than people think, and it will be more long term,” Farrar said. 

“If you think 20%-25% of colleagues lose their jobs, that’s extraordinarily difficult for any organization. It will be a human issue, not a technical issue, and we should never forget the human side of it. But we will emerge, I believe, in 2026 smaller, more focused, back to our core mandate, and I believe, better.” 

Increase in membership fees?   

From left to right: Germany’s Björn Kümmel; Global Health Center founder Ilona Kickbusch; Thailand’s Suwit Wibulpolprasert and UN Foundation’s Cecilia Mundaca Shah.

Against the dark budget horizon, there is one bright spot. Hopefully at this year’s WHA, the WHO member states will agree to raise their own assessed annual contributions by 20% for yet a second time over the past two budget cycles. 

But a positive WHA decision shouldn’t be taken as a given, warned Germany’s Björn Kümmel. The senior global health advisor in the German Health Ministry has been the leader of an longstanding initiative to raise member state fees, and thus put WHO on a more stable financial footing.

The negotiations finally led to a 2022 WHA agreement in principle to increase assessed contributions in a step-wise manner over a period of years, to a level equalling about 50% of WHO’s budget by 2030.  But the plan has to be reaffirmed at each new rung in the ladder.  

“We are keeping our fingers crossed that we will have a consensus on this in the assembly,” he said, of the pending increase. “But it’s not a given that it will happen.”

“The African countries, the European countries and many Asian countries are in favor, but there are also other countries who remain very quiet and who naturally do not want or have challenges in their domestic settings to argue in favor of a 20% AC [assessed contributions] increase.

“I think there’s still work to do, even during this assembly, to lobby,” he said, warning that if the increase is not approved, “WHO will be even in a deeper financial crisis.” 

WHO’s faltering investment round 

Brazil’s President Lula da Silva with WHO Director General Dr Tedros Adhanom Ghebreyesus at a WHO “Investment Round” pledging session on the margins of the G20 in Rio in November 2024. Neither Brazil nor other countries in the Americas have yet made pledges.

Member states in other middle- and even high-income regions also need to step up  to the bat with more voluntary donations to WHO’s new “investment round” mechanism, Kümmel said, noting that since the US departure, roughly 80-90% of voluntary funds for WHO is coming from Europe alone. 

“We have a complete imbalance between the membership of this organization and the financial contributions, and that will not be sustainable for the future,” he said. 

“Emerging economies need to come in. It’s completely unsustainable if a number of five, six or seven member states pays for us all,” Kümmel warned. 

“Plus, there is one region that doesn’t contribute at all to the financing of WHO,  at least through the investment round. And we need to say: why is that? How can we incentivize that region to do so, I don’t know.” 

According to the WHO list, the Americas is only region not to have made voluntary funding commitments to the investment round. Along with the USA, that region includes other high-income countries like Uruguay and Canada, as well as upper-middle-income Chile, Mexico and Brazil. Brazil even hosted a WHO funding event on the margins of November’s G20 Summit, in Rio but has made no pledges itself. 

At the same time, WHO’s Regional Office of the Americas/Pan American Health Organization (PAHO), is almost wholly funded by member states in Latin America and North America. And PAHO is reportedly facing its own funding challenges although the US has not technically withdrawn from the continental body, which it helped found over a century ago. 

Pandemic agreement: still a way to go even once its approved by WHA

Jubilant and exhausted WHO member state negotiators on 13 April, after marathon talks finally result in a draft pandemic agreement to submit to WHA.

As for the Pandemic Agreement, WHA approval of the instrument this week will not be the final stop. Another round of negotiations on an annex that would develop e pathogen access and benefit-sharing (PABS) system is required before it can actually be ratified by member states, Burci explained.

Such a system has been difficult to devise due to the complex set of interests at stake. Developed countries are concerned about ensuring free access to pathogen samples and their genetic sequencing to accelerate the development of medical products urgently needed in a pandemic.

Developing nations want an assured supply of “benefits” in terms of medicines and vaccines if they share pathogen information, which were often scarce during the COVID pandemic. At the same time, fixed formulas for “benefit sharing” are also challenging to devise, given the variables that can emerge during a pandemic in terms of medicine and vaccine needs.

“While we will adopt the agreement, we will not open it for signature right away,” Burci said. “Why? Negotiators could not reach agreement on the details of the [PABS] arrangement in time for the WHA.  That will be negotiated after the adoption of the main text of the Pandemic Agreement.  

“Once the annex is adopted, the agreement will be unfrozen and open for signature, together with the annex. So it’s quite an unusual process, but it was the only way to have this political package come together.”

Big achievements despite all 

WHO’s Geneva Headquarters

With all of the caveats that still involved, “I think it is important just to reflect that.. at a time of fragmentation and geopolitical tensions, the fact that 193 [out of 194] countries have come together to, in theory, approve a pandemic accord is a remarkable achievement,” added Farrar. 

That, together with an agreement on raising member state levels of assessed contributions would spell success, he said, for this year’s WHA. 

“Those two things together really have to give you a sense that [speculation over] the death of multilateralism is actually grossly exaggerated,” observed Farrar.  

“Yu have to hold on to that optimism and hope, because otherwise it’s difficult to see anything other than a slightly nihilistic future.

“And if you give in to nihilism and pessimism, then the arguments for a better world are lost. So no matter how hard it is, …and what the impact the current disruption is having, you have to come through that.

Because otherwise you will not, at least, I personally cannot, be creative in terms of thinking of how to address future challenges.”

Image Credits: ©The Rudin Group , Health Policy Watch , Twitter, WHO , Thiru Balasubramaniam, Wikipedia .

Newly-elected African Regional Director, Dr Mohamed Yakub Janabi.

Dr Mohamed Yakub Janabi, of Tanzania, was elected as the new African Region nominee for Regional Director, in a special meeting of the WHO African Regional Committee on Sunday – replacing fellow Tanzanian, RD-elect Dr Faustine Ndugulile, who died suddenly in November, 2024.

The WHO Executive Board will be asked to approve Janabi’s nomination at their meeting immediately after the World Health Assembly, clearing the way for his formal appointment by WHO Director General Dr Tedros Adhanom Ghebreyesus.

Janabi beat out three other candidates in secret voting by the committee, which followed a series of presentations and interviews of the four candidates at Sunday’s meeting. They included candidates proposed by ​​​​Côte d’Ivoire, Togo, and Guinea.

A senior health advisor to Tanzania’s late president and its present head of state, Samia Hassan, Janabi is a cardiologist by training and the former executive director of Tanzania’s largest hospital.

Born in 1962, his career spans over three decades of work in clinical and policy settings, from the early days of the HIV epidemic to his role today as presidential advisor, he noted, in his presentation before the African Regional Committee.

Hardships caused by out-of-pocket expenses

Janabi said his first priority as Regional Director would be achieving Universal Health Coverage for the African Region, reducing catastrophic health expenses that cause financial hardship.

“During the course of my duties, I have witnessed, first hand, patients being denied access to health care due to financial constraints, families parting ways with their position, their very means of living just to pay hospital bills,” he told the Regional Committee.

“Yet, despite making these heartbreaking sacrifices, many still find themselves trapped in debt and still in poor health conditions. For me, this is a harrowing experience out of pocket, costs have pushed countless families into the depths of poverty, thereby recycling poverty.”

He also noted his  involvement in HIV vaccine trials in Tanzania and Mozambique in the early 2000s, and later, public health advocacy that convinced Tanzania’s then-president to get a public HIV test, “encouraging 5 million Tanzanians to get tested that year.”

In 2021, he supported Tanzania’s new president, Samia Hassan, in devising a new, COVID-19 vaccination strategy, “which played a key role in countering misinformation and boosting vaccine uptake,” he noted. Hassan took over following the death in March 2021 of then-President John Magufuli, a COVID vaccine skeptic, who ultimately succumbed to the virus himself, according to some reports.

Janabi also is the founder of the Jakaya Kikwete Heart Institute in 2014, which he claimed achieved a “95% reduction in overseas heart disease referrals” within five years of its founding.

Building health systems on primary health care

Other priorities he cited would include supporting larger fixed contributions to WHO from member states “for more predictable, flexible and sustainable investment” along with stepped up domestic financing for health systems – through blended financing, private-public partnerships and solidarity levies.”

Building emergency preparedness, including through cross border collaborations, as well as advancing maternal and child health, along with nutrition, are other high priority items he said, noting that 70% of maternal deaths and 56% of deaths of children under the age of 5 still occur on the continent.

Janabi also pledged to tackle infectious diseases as well as non-communicable diseases through a “One Health” approach that  “acknowledges the interconnectedness of humans, animals and the environment” – as well as tackling antimicrobial resistance, through better surveillance systems, as well as strengthening local production of diagnostic, therapeutics and vaccines “by leveraging the pandemic agreement” – the new accord expected to be approved at this year’s WHA.

He added that primary health care and Community Health Worker networks need more investment as the backbone of health systems – noting that in high-income countries nurse practitioners carry out many functions that doctors used to perform.

“You have to build on your community health workers, because these are the people who have the trust. They are the people who are communicating with your general population every day,” he said, adding, “There’s other thing, which unfortunately is not very prominent in Africa. They are called nurse practitioners… So if they get training on basic things like immunization, maternal and child health, education, these efforts will improve access.”

Janabi, once confirmed by WHO’s Executive Board and formally appointed by the DG, will step into the shoes of the late RD-elect, Nduguilile, who died on November 27, 2024, at the age of 55, while receiving medical treatment in India.

Ndugulile, a former Tanzanian Deputy Health Minister and member of parliament had been elected as the WHO Africa Regional Director in August of 2024 and was scheduled to begin his term in February 2025. His death led to a special session of the WHO Regional Committee for Africa in January 2025 to decide on a new election process. Dr Matshidiso Moeti had been the WHO Africa Director for two terms before Ndugulile’s election.

This week’s budget discussions take place just ahead of the WHO’s World Health Assembly, convening next week at Geneva’s Palais des Nations 19-27 May.

WHO’s budget for 2026-27 could reduce the agency’s global footprint by about 20% from a total of 9,463 staff as of December 2024, to 7,525  – with the biggest cuts in entry-to mid-level professional staff who are ranked as P1 to P3. 

Some 30% of staff P 1-3 in 400 positions would be terminated, according to initial estimates of staff allocations by grade, contained in a confidential white paper presented this week to the WHO’s Planning, Budget and Administration Committee (PBAC) of the WHO Executive Board, and seen by Health Policy Watch.

The PBAC meeting came ahead of next week’s World Health Assembly (19-27 May), when member states will consider a draft resolution approving a base budget of $4.2 billion and a total budget of about $6.2 billion, including voluntary donations for polio eradication and emergency appeals.  

Only six D2 directors would leave the agency—just a 9% reduction in the agency’s most senior directors—according to an “indicative summary staffing table” in the white paper presented to PBAC, covering the $4.2 billion base segment of WHO’s 2026–27 budget. The estimates, like all published WHO HR data, do not include staff in the Regional Office of the Americas (Pan American Health Organization/PAHO), which has a separate budget—except for the head of PAHO’s Regional Office, who is paid by headquarters.

The number of senior directors nearly doubled between July 2017 and July 2024 as WHO Director General Dr Tedros Adhanom Ghebreyesus expanded numbers of both staff and senior management, while promoting many existing directors from D1 to D2 grades, during a period of rapid WHO expansion.   

If the white paper projections were indeed implemented, there would be only a net global reduction of just 32 directors at D1 to D2 levels, according to a comparison of current and planned 2026-27 staffing levels by Health Policy Watch.   

HP-Watch assessment of projected WHO staffing for the 2026-27 budget, presented this week to PBAC, as compared with December 2024.

The number of staff in senior leadership positions, so called “ungraded” (UG1-UG2), would, meanwhile, decline from 16 to 13. That would include the heads of WHO’s six regional office as well as a deputy director general in a seven-member leadership team at WHO’s Geneva headquarters.

That contrasts with the latest organigram presented to WHO member states, which noted a leadership team of only six alongside the director general himself. In that array, there was no deputy director general earmarked at all, a position estimated to cost more than $500,000 a year. No deputy director general was named, as well, in the recent announcement by Tedros’ of his new senior leadership team.

New WHO organizational plan, announced 22 April, reduces 10 divisions at headquarters to just four.

The global staffing plan, seen by Health Policy Watch, also seems to anticipate a net reduction of D1 and D2 directors that is far less than had been promised for headquarters alone.  

In his presentation Wednesday to the PBAC, Tedros told member states that the number of departments at headquarters would be reduced by more than half from 76 to 34. That should, in principle, lead to 42 fewer directors in headquarters. 

“Decisions about which directors will lead which departments will be made following the World Health Assembly. That, I know, will also be tough, given the downsizing from 76 to 34 departments,” Tedros said in his message to PBAC members, which was published by WHO.

At the same time, 90% or more of directors have long term contracts that protect them from sudden layoffs, complicating such reductions. According to UN rules, those who see their programmes at headquarters slashed or eliminated would have to be offered positions elsewhere in the global system – or alternatively a year’s salary – with all of those associated costs. 

All short term professional and administrative staff eliminated 

In contrast, short-term professional and administrative staff would be eliminated almost entirely from the organization’s ranks in the new staff planning, as they have almost no protection from layoffs whatsoever. 

But cost forecasts also contained in the white paper suggest a continued heavy reliance on WHO consultants over the coming two years. 

HPW rendering of projected WHO budget costs, by category, 2026-27, as per a White Paper presented at WHO’s PBAC meeting this week.

The paper estimates the cost of “contractual services” – meaning consultants – at some $1.19 billion – or around 52% of total staff costs of $2.26 billion for the same period. And that does not include contractual services for general operating expenses, such as building maintenance, or equipment, vehicles and furniture. 

The budget total adds up to $4.267 billion, equal to the base budget that WHO member states will be asked to approve for the coming biennium at the upcoming WHA, in a draft resolution published on WHO’s WHA website.  On top of the base budget are WHO’s polio eradication effort, Special Programmes, and Health Emergency appeals, which depend heavily on voluntary contributions and add another $2 billion, for a total of $6.206 billion, not including PAHO, included in the draft  2026-27 Programme budget resolution that will go before member states.  Currently, however, some $1.7 billion of even the base budget remains unfunded. 

From July 2017 to the end of 2024, the number of WHO consultants in all categories increased from 3,798 to nearly 7,600, according to a Health Policy Watch analysis of the data in March. 

Sources: Based on WHO HR reports for 2017 and 31 July 2024. Covers all three categories of consultants: Agreement for Performance of Work (APW); Consultancies; and Special Services Agreements (SSAs).

WHO’s end-year 2024 HR data, however, reflected a reduction in “non-staff” positions as compared to the previous year. As of end 2024, there were some 7582 “non-staff affiliates” in all categories, up just three positions from July, but down by nearly 15% from the all-time WHO peak of 8818 non-staff affiliates in 2023.

Asked to comment on the White Paper and its consequences, a WHO spokesperson said:

“The HPW article is misleading. The paper it refers to is a modelling exercise done primarily for budget modelling purposes. It is also missing some elements—e.g., country data from Europe. Under no circumstances should this be viewed or considered to pre-empt the actual managerial decisions which are about to take place in the coming months. Those decisions will be made based on prioritization, looking at synergies and eliminating duplications. The only layer where decisions were made is at the Assistant Director-General level so far. We haven’t gone through any other functional review. It would be more appropriate to wait for these decisions—we will report everything properly—and analyse them then. To draw any conclusions from this at this point is not meaningful or helpful.”

Indeed, along with the routine exclusion of PAHO, the data “does not include country level positions for the regional office for Europe,” the White Paper states.

The White Paper also states that the staffing and expenditure breakdown are “solely for indicative purposes. Staffing figures will evolve once operational planning has been concluded. The actual implementation of the workplan plans will be subject to the availability of funding.”

However, the fact remains that with large proportions of higher-level staff on long-term contracts that make lay-offs difficult, large reductions of staff in the organization’s lower ranks are much easier legally and financially.

WHA will review latest updates on the budget crisis

Next week’s World Health Assembly will review a summary report from the closed-door PBAC session, along with the latest updates from the WHO’s leadership on the budget crisis, triggered by the withdrawal of the United States, WHO’s largest donor, from the global health agency in January.

The member state group will also discuss the ongoing “prioritization” exercise aimed at determining which WHO programmes and activities are deemed less essential and should therefore be discontinued in light of the pending budget and staff reductions.

Strikingly, the PBAC White Paper—as well as other documents presented to PBAC on WHO’s financial outlook—only discloses total staff costs to the organization in the aggregate, rather than providing any assessment of costs by staff grade, type of contract, and geographic location.

Knowledge of the real costs of staff at different levels would enable nuanced member state assessment of the tough financial tradeoffs faced, analysts say—for instance, between offering early retirement versus relocation to senior directors and high-ranking professionals; options for retaining more staff in mid- or lower-level ranks; and costs of consultants versus staff for certain types of tasks.

So, amidst the extensive documentation prepared for PBAC and the upcoming WHA, the lack of detailed cost disclosure remains a glaring omission.

  • Updated on 17.05.25 to include WHO’s response and the exclusion of PAHO from the budget and staffing estimates in the exercise. 

Image Credits: WHO/Pierre Albo , WHO HR Update 31.12.2024 & PBAC White Paper , WHO, White Paper, PBAC.

A child with HIV takes a paediatric dose of antiretroviral medication. Many paediatric HIV trials were conducted in South Africa over the past 20 years.

Essential research on tuberculosis and HIV cancelled. Clinical trial participants in limbo. Young researchers’ careers halted  – and billions of dollars invested and expertise developed over 30 years potentially down the drain.

These are some of the impacts on South Africa of the decision by the National Institutes of Health (NIH) barely a week ago to prohibit United States scientists from working with foreign researchers via “subawards”, leading to the immediate and mass cancellation of such grants with South African institutions.

At least 39 TB and HIV clinical research sites in South Africa are under threat due to NIH funding cuts, jeopardising at least 27 HIV trials and 20 TB trials, according to an analysis by the Treatment Action Group (TAG) and Médecins Sans Frontières (MSF) drawn mostly from the NIH’s Division of AIDS (DAIDS) presented at a media briefing on Thursday.

Impact of NIH cuts on TB and HIV research in South Africa

TB trials at risk include testing potential vaccines and new drugs; shorter, safer regimens, and the best treatment for TB meningitis. 

The HIV trials at risk include cure-related treatments involving broadly neutralising antibodies (bNAbs); vaccines designed to prime the body to make bNAbs; the impact of hormone treatment on women with HIV and treatment options for pre-exposure prophylaxis to prevent HIV.

Many of these trials are global, with South Africans making up 30-50% of global trial participants and 50-90% of trials on interventions for children and pregnant women, said Lindsay McKenna, TAG’s TB project co-director.

She estimates that the average investment in each trial participant is $12,000 – potentially all wasted if the trials are discontinued, and some have been going for several years already.

For some 30 years, South African clinical studies have provided global guidance on issues including prevention of mother-to-child HIV infection, when to start children on antiretroviral treatment, how to simultaneously treat TB and HIV, as well as the safety of HIV and TB treatments. Meanwhile, operational research, such task-shifting from HIV doctors to nurses, has led to more efficiency and cost-cutting.

“NIH funding is not aid. It’s competitive funding that researchers here competed for that went through stringent NIH processes and committees,” stresses Marcus Low, an epidemiologist and editor.

The NIH cuts come on top of the cancellation of grants from the US Agency for International Development (USAID) and US Centers for Disease Control (CDC) – primarily for HIV and TB programmes.

Impact on institutions

“South African academic and research institutes could lose about 30% of their annual income and may be forced to lay off hundreds of staff as a result of US funding cuts,” the analysis notes.

It warns of “the potential collapse of TB and HIV research and development capacity” in the country, with global impact in light of “ the substantial contributions of South African research centres to advancements in TB and HIV prevention, treatment, and care worldwide.”

(From Top L-R) Lindsay McKenna, Ian Sanne, Tom Ellman, (Bottom L-R) Marcus Low, Ntobeko Ntusi and Linda-Gail Bekker
(Top L-R) Lindsay McKenna, Ian Sanne, Tom Ellman, (Bottom L-R) Marcus Low, Ntobeko Ntusi and Linda-Gail Bekker

Professor Ntobeko Ntusi, head of the South African Medical Research Council (SAMRC), told the media briefing that the country had been disproportionately affected both because of its high burden of HIV and TB and the excellence of its scientific community – making it a preferred site for research.

“Universities are now beginning retrenchments at scale,” said Ntusi, adding that affected scientists also provide postgraduate training.

“Hundreds of master’s, doctoral and post-doctoral fellows, whose stipends and research costs are dependent on these grants, find themselves in a position of inordinate precarity,” said Ntusi.

‘Ethical nightmare’

Prof Ian Sanne, co-principal investigator of the Wits HIV Research Group Clinical Trials Unit, describes navigating the US funding cuts as a “major regulatory and ethics nightmare”.

NIH investment in South African HIV and TB research “amounts to almost $2 billion over 20 years”, according to Sanne. His institution alone, Wits University in Johannesburg, stands to lose $150 million to $180 million in NIH funding.

As co-chair of Wits University’s ethics committee, Sanne has had to work with units on contingency plans for both staff and trial participants – despite US funds being terminated with immediate effect with nothing left over to wind down processes.

“In one of the studies in KwaZulu-Natal, the sponsor, USAID, stopped funding overnight and the microbicide rings that were under research with the participants were terminated without their knowledge,” said Sanne, leading to “a real ethical problem”.

Microbicide rings impregnated with ARVs are inserted vaginally to prevent HIV and studies often involve women at high risk of HIV infection.

Sanne’s unit lost US funding with immediate effect on 21 March – but it then had to embark on retrenchment procedures in terms of South African law, draining the reserves of the unit.

Expertise and infrastructure lost

Prof Linda-Gail Bekker, director of the Desmond Tutu HIV Centre at the University of Cape Town, says her centre will lose $6.9 million out of $10 million in NIH funds.

Earlier in the year, the centre lost a HIV vaccine grant worth $45 million over five years from USAID that would have seen five trials in eight southern African countries “contributing to the global quest to find an effective HIV vaccine”, she added.

The centre employs 400 people and will have to retrench “one-third to half our workforce”, said Bekker, whose groundbreaking research on a twice-yearly injection to prevent HIV infection earned her a standing ovation at the International AIDS Conference in Munch last year.

Professor Linda-Gail Bekker presenting the results of the PURPOSE 1 trial at the Munich AIDS conference, which found a twice-a-year injectable ARV prevented all women in the trial from contracting HIV.

“We have an incredible critical mass of very experienced and very well-established research organisations in the country, and the infrastructure that has been built over the last 30 years has established an extraordinary clinical trial infrastructure,” said Bekker.

South Africa was able to use this expertise and infrastructure during the COVID-19 pandemic to “pivot to test at great speed, new COVID-related vaccines”.

“Throughout the years, we have contributed to creating new knowledge that is often [Investigational New Drug] related studies… that feeds into important guidance, such as the WHO guidance.”

Impact on other African countries

Dr Tom Ellman, director of MSF’s Southern Africa Medical Unit, said that MSF has applied the “pragmatic” HIV and TB research generated in South Africa in resource-poor settings throughout the continent.

Recently back from the Democratic Republic of Congo (DRC), Ellman said it was able to draw on the “self-managed, fixed-combination antiretroviral treatment regimen” developed in South Africa for people living with HIV in the conflict zone in South Kivu.

MSF’s large HIV programme in Kinshasa relies on dolutegravir – “a basic, simple, effective drug enabled by South African research”, said Ellman, who listed several other drugs that had been trialled in South Africa before hitting the global market.

“The best science leads to impact in the most difficult settings. There’s no question that South African science has transformed access to HIV, TB and other disease responses across Africa and across the world.”

Ellman said the funds cut is “particularly awful”  as “we are closer than ever to finding ways out of the HIV, TB and malaria pandemics”.

Appeal for support

TAG, MSF and the SAMRC have appealed for “alternative funds to sustain TB and HIV research in South Africa”.

Ntusi says numerous donors and governments have offered support and solidarity – but most wish to remain anonymous at present.

The researchers all agreed that the most urgent need is to provide immediate support to clinical research sites to ensure continuity of care and follow-up for study participants. 

“South African trial participants must be supported to complete treatments safely and, in cases of treatment failure, be offered appropriate alternatives, and research sites must be supported to complete data collection and analysis,” said TAG and MSF.

Image Credits: Paul Kamau/ DNDi, IAS.

A billboard in South Africa in support of a tax on sugary drinks as part of a campaign in 2017.

Significant portions of health care budgets across Africa have vanished. Countries across the continent are grappling with the unprecedented scale and speed of recent reductions in development assistance for health.

In 2021, external financing supported more than a third of health expenditures in half of the countries in sub-Saharan Africa. While multilateral and bilateral development assistance for health, which have historically supported about 30% of health care spending, were expected to decline by 2050, the region was not prepared for a staggering drop from $80 billion in 2021 to $24 billion in 2025. 

The question is this: How will governments address these unplanned deficits, fulfill essential health care needs, and meet new demands created by demographic transitions, climate change, and the non-communicable disease (NCD) epidemic?

Solution in plain sight

There is a solution hiding in plain sight. Taxing harmful commodities to increase government revenue and reduce societal costs is a tool that has been around for centuries, dating back to the 17th century when sin taxes were imposed in England on tobacco.

More recently, the Task Force on Fiscal Policy for Health estimates that raising the price of tobacco, sugary beverages, and alcohol by 50% worldwide through excise taxes could prevent 50 million premature deaths over 50 years. Over five years, this solution would produce an additional $3.7 trillion in tax revenue worldwide, with more than half of that generated in low- and middle-income countries, enough to cover 40% of health budgets.

Over five years, this solution would produce an additional $3.7 trillion in tax revenue worldwide, with more than half of that generated in low- and middle-income countries, which is enough to cover 40% of health budgets. 

With crisis comes opportunity. Despite industry opposition and interference, conflicts of interests, and implementation challenges, now is the time to mobilize action around this solution.

Health taxes have the potential to boost budgets and save lives, particularly in the current funding crisis.

How to mobilise around health taxes – lessons learnt

At Vital Strategies, our partnerships with governments and civil society across more than 35 countries to help implement tobacco, alcohol, and sugary beverages taxes has provided some perspectives on how to overcome these barriers.

Our key message: We can apply lessons from multiple successful efforts to advance health taxes to tackle these barriers. Health taxes are achievable and deliver immense returns for population and financial health. Here are some important steps to success.

Rapid modelling

First, rapid modeling and assessment can create country-specific guidance on projected revenue gains and health benefits — data needed by decision-makers and legislators across health, finance, trade, and other ministries. Painting a picture of how these taxes yield tangible benefits  to make the case to policymakers and the public for action, or to document benefits of a new policy recently undertaken, should be part of this exercise.

In the Philippines, for example, taxes on tobacco and alcohol are helping to fund universal health care, while in Guatemala, revenue from alcohol taxes supports family planning programs. In Philadelphia, a sugary drink excise tax introduced in 2017 had generated more than $500 million by early 2024, helping to fund universal pre-kindergarten education for children across the city.

Prepare for pushback from industry

Secondly, anticipate and prepare for opposition from industry actors, who will inevitably work to block policies that threaten their profits.

Their tactics often include exaggerating claims of economic harm, denying the health harms of their products, and spreading disinformation on taxes’ impact on the economy, jobs, illicit trade, and the well-being of lower-income people.

But in country after country, smart tax policies demonstrate that these claims don’t hold up. When the prices of harmful products increase, worker productivity improves, and people shift their spending to other sectors, resulting in a net impact on employment and economic growth that is neutral or positive.

And taxes are not the primary drivers of illicit trade. Non-price factors, such as governance status, a weak regulatory framework, and the availability of informal distribution networks appear to be far more critical.

Effective dialogue with the public 

When Mexico launched it’s one-peso soda tax, it also launched a campaign explaining that a single 600ml soda had an average of 12 teaspoons of sugar. Sales of sugary drinks decreased 6.3% in the first year.

The final step is to build broad public support by highlighting how these measures benefit children, families, and communities, creating the momentum needed to overcome industry resistance and drive political buy-in.

We know that public support for health taxes is strong when benefits are clearly communicated. A Gallup study across India, Colombia, and Tanzania found up to 74% of adults supported higher taxes on alcohol, tobacco, and sugary drinks. Effective dialogue with the public fosters trust and aligns fiscal policies with community priorities.

In the Philippines, for instance, a concerted public campaign reframed ‘sin’ taxes as a means to help fund universal health care.

Guatemala’s experience offers a similar lesson. After a law was enacted allocating 15% of alcohol tax revenues to family planning programs, communication campaigns were launched to inform citizens about the benefits of this allocation. 

The introduction of a tax on sugary drinks was strategically communicated as a means to fund universal pre-kindergarten education in Philadelphia. This framing resonated with the public, leading to the tax’s approval and the generation of over $500 million by early 2024, with a portion allocated to early childhood education programs. ​

In December 2024, Brazil’s National Congress approved a tax on tobacco, soft drinks and alcohol. Health taxes in Brazil were framed as a mechanism to address deep-rooted health inequities, designed to shift the burden of harm from society back to the industries profiting from it, and using policy to reduce disease burden where it’s most concentrated: low-income and underserved communities. 

When there are clear benefits to be gained, such as better health and better social services, the public supports taxation on unhealthy products. 

Few African countries tax tobacco, alcohol and ultraprocessed food effectively, in part due to massive industry pushback.

Altering the trajectory of health inequities 

Non-communicable diseases such as cancer, heart disease, and diabetes, once mostly occurring in wealthy nations, is shifting to emerging markets.

Africa is witnessing some of the fastest growth rates in the consumption of unhealthy commodities; this increase is concentrated in lower-income households and among youth. Currently, consumption of these commodities is linked to 3 million deaths a year. NCDs account for an estimated  29% of all deaths in Nigeria, 38.5% in Kenya, and 51% in South Africa. If we allow the status quo to continue, low- and middle-income countries will see about a 50% increase in NCD deaths by 2030, with Africa a major contributor, resulting in $500 billion to $1 trillion in economic losses by 2030.

This does not have to be our future. Young people and lower-income households are especially sensitive to price.

After the implementation of the Health Promotion Levy in 2018, South Africa saw the sugar content of beverage purchases fall by 32%, with greater reductions seen in lower-income households. In Mexico, after the introduction of a soda tax, sales of sugary drinks fell by 6.3% in the first year. Within two years, rates of overweight and obesity among adolescent girls dropped by 3%. With an average population age of 19, price increases on unhealthy commodities can have an outsized impact on Africa’s development trajectory.

Sugary drinks have become popular in Africa, and are driving NCDs including obesity and diabetes.

In the case of Brazil’s new tax on tobacco, soft drinks and alcohol, rather than taking a piecemeal approach, Brazil’s reform adopted a comprehensive reform grouping  tobacco, alcohol and sugary drinks with other harms like coal and betting. 

The reform established an equity-driven National Basic Food Basket (CBNA) exempt from taxation to promote healthier consumption, including meat, poultry, fish and minimally processed foods. 

The legislation also includes annual tax adjustments tied to inflation to maintain the effectiveness of these taxes over time, and this year, lawmakers will determine the specific tax rates on harmful products. The tax rates it adopts and the resulting changes in consumption, health outcomes and health disparities will be something to watch, as Brazil must establish those rates at levels that significantly reduce consumption to generate real public health benefits.

What are we waiting for?

Health taxes remain an undervalued and underutilized solution to address the triple shocks of contracting donor funding, domestic fiscal tightening, and the growing health care burden, providing governments with a unique opportunity to improve both long-term population and fiscal health. Now, when there is political and economic pressure to establish more stable and sustainable sources of domestic revenue for health, is the time to come together across sectors and mobilize for health taxes. Future generations will thank us.

What are we waiting for?

Dr Mary-Ann Etiebet is the President and CEO of the New York City-based Vital Strategies, a global health non-profit working in more than 80 countries to advance  equitable public health systems, including through stronger action on the drivers of non-communicable diseases. 

Image Credits: Kerry Cullinan, Bllomberg Philanthropies, Alianza por la Salud Alimentaria, Leo Zhuang/ Unsplash, Heala_SA/Twitter.

A nurse tests a patient for hypertension. Two-thirds of Africans with high blood pressure are unaware of their condition.

Three key issues feature in the United Nations zero draft of the political declaration on non-communicable diseases (NCDs) and mental health, published on Thursday in preparation for the High-Level Meeting on 25 September.

Tobacco control, hypertension and improving mental health care are the cornerstones of proposed action to contain NCDs. The draft proposes 2030 global targets of 150 million fewer people using tobacco, 150 million more people controlling their hypertension and 150 million more people having access to mental health care.

Five sub-targets are included in the 10-page draft as the pathway to achieving the three “150 million” targets by 2030.

The first focuses on at least 80% member states countries implementing excise taxes on tobacco, alcohol, and sugar-sweetened beverages at levels recommended by the World Health Organization (WHO).

The second is for 80% of public primary health care facilities in all countries to have “uninterrupted availability” of at least 80% of World Health Organization-recommended essential medicines and basic technologies for NCDs and  mental health conditions at affordable prices by 2030.

Other targets relate to limiting the cost of essential NCD and mental health “services, diagnostics, and medicines”, integrated country-based frameworks and surveillance and monitoring.

Member states have a tight window – until 27 May – to submit written comments on the draft ahead of the first round of negotiations on 5 June. 

No mention of fossil fuel

The NCD Alliance (NCDA), which has been leading civil society mobilisation ahead of the HLM, told Health Policy Watch that it is currently studying the draft and will formulate its response early next week, and will share its analysis at a public webinar on 20 May.

However, an NCDA advocacy briefing outlines its key asks, including universal health coverage (UHC) and achieving the Sustainable Development Goal (SDG) target on NCDs. 

Seventy percent of deaths are caused by NCDs, as unhealthy diets, lack of exercise, smoking, air pollution, and poor mental health take their toll globally. Yet only 19 countries are on track to achieve SDG 3.4 to reduce premature mortality from NCDs by one-third by 2030.

Several of the NCDA asks are in the draft, but perhaps not as strongly stated as it would like.

For instance, while the draft identifies the need to reduce air pollution – the second biggest driver of NCD deaths after tobacco –  there is no mention of the cutting back on fossil fuel use.

The draft proposes that a reduction in air pollution can be achieved through clean urban transport, reducing burning of agricultural residue, and access to “affordable and less polluting fuels for cooking, heating and lighting”.

The NCDA wants interventions to “reduce air pollution and fossil fuel use” – and for government policies to be protected from the influence of the fossil fuel industry. 

The draft’s only reference to climate change is its acknowledgement that countries’ resources are strained by several emergencies including “climate crises” – whereas the NCDA wants policies to cost health and climate, reduce fossil fuel use, and ensure funding for vulnerable countries, particularly Small Island Developing States (SIDS). (The draft does acknowledge the “unique vulnerabilities” for people living in SIDS.)

Increased funding

“The last decade has been coined as a policy success, but an implementation failure. This HLM has to change this, renewing commitments to cost-effective policies that we know work to reduce the risk factors and improve access to care,” Katie Dain, NCDA CEO, told a recent multi-stakeholder hearing called by the UN Secretary General ahead of the HLM.

Dain added that the HLM “must address the glaring mismatch between the scale of the burden of NCDs and the level of funding”.

“We urge governments to increase sustainable financing for NCDs by adopting specific and measurable financing targets for NCDs and improving financing data and tracking, as well as committing to health taxes that have a triple win of raising revenue, improving health outcomes and reducing long-term healthcare costs.”

The draft devotes five points to increased budgets, which call for increased domestic resources (helped by funding from the excise taxes), more donor resources and strategies such as pooled procurement for medicines.

It also calls on countries to “urgently scale up the percentage of public health budgets dedicated to mental health with the aim to increase the current global average of 2% to at least 5% by 2030”.

Human rights approach

Importantly, the draft stresses the importance of adopting a human rights-based approach, acknowledging that people living with NCDs and mental health issues are “routinely and unjustly deprived of such access and discriminated against”.

It also calls for measures to decriminalise suicide, which was a key demand made by civil society groups at the recent multi-stakeholder hearing.

Image Credits: Hush Naidoo Jade Photography/ Unsplash.

Jubilant and exhausted members of the Intergovernmental Negotiating Body (INB) pose after marathon pandemic agreement talks finally resulted in agreement in the early hours of 16 April.

The final draft of the pandemic agreement for the World Health Assembly (WHA) next week was published by the World Health Organization (WHO) on Wednesday – along with a document outlining the long road member states still have to travel before it is enforced.

This follows the historic agreement reached on the text in the early hours of 16 April after three years of talks on how to prevent, prepare for, and deal with, future pandemics in an equitable manner – unlike what happened during COVID when wealthy nations hoarded vaccines at the expense of low- and middle-income countries.

The procedural document outlining the steps to adoption, which will be done in terms of Article 19 of the WHO Constitution, makes sobering reading.

While the agreement needs a two-thirds vote to pass, “adoption of the text by consensus automatically fulfils this requirement”, it notes.

Once the WHA has adopted the agreement via a resolution, it will be deposited with the Secretary-General of the United Nations, who will ensure it is prepared in various languages for signature.

Member states are expected to notify the WHO Director General on whether they intend to accept the agreement within 18 months of its adoption by the WHA.

Still more PABS negotiations

But member states’ signature of the pandemic agreement will only happen after the adoption of an annex on the much-contested Pathogen Access and Benefit-Sharing (PABS) System – a mechanism on how to share information about pathogens with pandemic potential and any possible benefits (such as vaccines and therapeutics) that might arise from sharing this information.

This annex – called the PABS instrument – still has to be negotiated, and it deals with a range of issues including “the provisions governing the PABS System, definitions of pathogens with pandemic potential and PABS Materials and Sequence Information, modalities, legal nature, terms and conditions, and operational dimensions”.

This means the PABS can of worms will be reopened in the coming months and member states will once again have to find agreement on this highly contested subject.

Only once the annex has been agreed, will the WHO Pandemic Agreement be open for signature by heads of state.

But even once the heads of state have signed the agreement, countries are not bound by its provisions. 

Instead, by signing, a head of state would be “expressing political approval of the treaty concerned, and raises an expectation that the signatory will in due course take the appropriate domestic actions to become a contracting party”. 

However, before domestic ratification, member states that have signed the treaty will be expected not to undermine the agreement.

Countries that have ratified the pandemic agreement will then be expected to deposit instruments of ratification with the UN Secretary-General and once 60 countries have done so, it will come into force and the first Conference of Parties will be held.

The entire process is likely to take several years, during which time another pandemic can engulf the world.

The Pandemic Agreement still has to pass through several hoops, including more negotiations on a PABS System, before it comes into force.

 

Image Credits: Thiru Balasubramaniam.