pandemic
USAID assisted health workers in Guatemala to maintain antenatal services and social support for pregnant women during COVID-19.

The list of United States Agency for International Development (USAID) projects that the Trump administration has cancelled runs to 368 pages and provides a rare glimpse of the extent of the US international influence.

READ HERE: USAID Terminated Awards (6 March 2025)

Projects vary from huge infrastructure support programmes (14 to unspecified countries worth $800 million each) to a $10 million investment in developing insect-resistant eggplants.

They range from supporting famine early warning system networks (three projects worth $900 million each) to establishing an American Chamber of Commerce in Belarus. Almost every country is affected – from Albania to Zambia.

A huge $520 million ‘Prosper Africa’ programme to foster trade between the US and Africa has been terminated, and so too have programmes to improve the soybean yield in sub-Saharan Africa and to assist African health ministries to deal with infectious diseases.

There are some surprises. Venezuela received a few grants, including one to secure its agricultural sector. Although the communist government of Venezuela is a sworn enemy of the US, it was no doubt prudent for the US to try to support the country to stem the tide of immigrants.

Grants were also made to Iraq and Syria for “technical assistance to repatriate families” and to assist with child immunisation despite the rancour between the US and those countries.

Grants for “humanitarian assistance for persecuted people in Cuba” and to promote “religious and ethnic freedom” in Asia were also cancelled.

Numerous projects aimed at bolstering food security, and combatting malaria, tuberculosis and HIV were also canned. 

So too were projects to combat corruption and cybercrime. The door is wide open for new donors – and criminals – to take advantage of the resource vacuum. 

HIV sector warns of millions of deaths

Earlier this week, over 530 HIV doctors, researchers, scientists, and public health experts gathered at the 2025 Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco wrote to Rubio calling for “an urgent reversal of recent decisions by the Trump administration that are doing catastrophic harm to the global and US response to the AIDS pandemic”.

The signatories wrote that the termination of projects on 26 February – “virtually eliminated” all US President’s Emergency Plan for AIDS Relief (PEPFAR) programming implemented by USAID, and US-supported malaria and tuberculosis programmes – will “result in millions of preventable deaths around the world while decimating global progress over the last 25 years”.

They also expressed alarm at the defunding of clinical trials that have “stranded study participants without clinical support” and the stripping of scientific institutions of staff and funding.

“Over time, these policy decisions may be proven illegal in US courts but the human suffering and loss of lives happening now cannot be reversed by any court order,” they note.

Meanwhile, the US State Department has refused to comment on reports that over 700 diplomats have signed a letter addressed to US Secretary of State Marco Rubio condemning the cuts for endangering US security.

An extract of the letter, said to have been filed on a staff channel that allows anonymous contributions, says: “The decision to freeze and terminate foreign aid contracts and assistance awards without any meaningful review jeopardizes our partnerships with key allies, erodes trust, and creates openings for adversaries to expand their influence.”

An online group to track job losses from USAID closures, USAID Stop Work, estimates that over 50,000 US citizens and 100,000 global workers have lost their jobs. It has been able to confirm 14,762 US jobs and 64,910 global jobs lost so far.

Image Credits: MSH.

Marburg containment
Health workers contain the highly fatal Marburg virus during an outbreak.

Tanzania has extinguished a deadly outbreak of Marburg virus, but elsewhere across Africa, an alarming surge of health crises continue to unfold – including expanding mpox infections in Uganda, a cholera outbreak in Angola and a first-ever cholera case in neighbouring Namibia.

The Marburg virus outbreak in Tanzania has officially ended, Tanzanian health authorities declared Thursday, marking a pivotal achievement in the continent’s ongoing battle against highly lethal infectious diseases. The success reflects the effectiveness of the coordinated international health response, said Jean Kaseya, Director General of the Africa Centres for Disease Control and Prevention (Africa CDC), commending the Tanzanian government’s swift and decisive action at a press briefing on Thursday.

Infamous for its haemorrhagic fever, Marburg virus kills up to 88% of those infected, posing a significant threat after it rapidly spread across Tanzania. The outbreak, declared on 20 January 2025, resulted in 10 fatalities –  eight probable and two laboratory-confirmed cases. Tanzanian authorities implemented containment measures, with substantial technical and logistical assistance from the World Health Organization (WHO) and Africa CDC, including disease surveillance enhancements and extensive frontline health worker training.

WHO’s Regional Office for Africa confirmed that the outbreak officially ended after 42 days had passed without new cases, meeting the criteria to declare an outbreak over; it commended Tanzanian authorities for prompt action in squashing the outbreak. 

WHO, Africa CDC cooperation to quell Marburg

This marks Tanzania’s second successful containment of Marburg, following an outbreak in the same northeastern Kagera region in 2023. In this year’s outbreak, WHO said it collaborated with Tanzanian health authorities to scale up surveillance and response activities, training over 1,000 frontline health workers in contact tracing, clinical management, and risk communication, and delivering over five tonnes of essential medical supplies.

Dr Jean Kaseya, Africa CDC Director General, commended Tanzania’s swift response.

“While the outbreak has been declared over, we remain vigilant to respond swiftly if any cases are detected and are supporting ongoing efforts to provide psychosocial care to families affected by the outbreak,” said Charles Sagoe-Moses, WHO Representative in Tanzania.

Kaseya also emphasized Africa CDC’s supportive role, including substantial assistance in laboratory reinforcement, provision of diagnostic kits capable of thousands of tests, and extensive healthcare worker training programs. These interventions enabled rapid case identification, isolation, and treatment – crucially preventing the virus’s broader spread.

Persistent health emergencies across Africa

A new and more deadly variant of Mpox continues to threaten 16 countries.

But even as Tanzania celebrates its victory over Marburg, outbreaks of mpox, Ebola, cholera, and COVID-19 are placing immense pressure on healthcare systems across Africa, revealing systemic weaknesses and vulnerabilities, Kaseya emphasized.

Uganda continues to face a troubling escalation of mpox – even though although recent weeks have seen no new cases of the even more deadly Ebola virus. Uganda’s mpox epicenter is in the country’s south-central region around the capital Kampala area.  And nearby, on the shores of Lake Victoria, the overwhelmed Entebbe treatment center has seen most of Uganda’s mpox-related fatalities. Kaseya emphasized the urgent need for expanded isolation facilities, increased healthcare staffing, and strategies for home-based patient care to manage mild cases effectively.

Meanwhile, the Democratic Republic of Congo (DRC) presents its own complex scenario, further complicated by continuing violence and instability in the North and South Kivu regions of Eastern DRC, where Rwanda-supported M-23 militia have made big inroads against government forces. Over 600 mpox patients fled treatment centers in the regional capital of Goma, Bukavu and other areas that were overrun by rebel forces, creating significant challenges in tracking and managing the disease. There are intensified efforts to establish humanitarian corridors, involving community health workers tasked with locating and reintegrating affected individuals into the health system. However, until a cease-fire is reached, insecurity will likely hamper those efforts, Kaseya said. 

Funding shortfalls threaten containment efforts

Cholera Namibia 2025
Namibia reported its first cholera case in over a decade, highlighting vulnerabilities in the continent’s health infrastructure.

Kaseya also revealed that funding shortages present a severe obstacle. Dramatic cuts to international aid, notably from traditional donors such as the United States and the United Kingdom, have only exacerbated the situation. These reductions, he said, significantly affect Africa’s capacity to manage public health crises effectively, creating urgent shortfalls in vital resources needed for outbreak response and containment efforts.

“Mpox remains a serious concern,” Kaseya warned. “We are facing a critical risk. Without sufficient vaccines, we will inevitably see more cases.”

The financial strain extends beyond mpox. Angola now faces an ongoing cholera outbreak, for which Africa CDC is providing emergency support, delivering 2,000 doses of oral cholera vaccines. Primarily affecting children, the cholera crisis in Angola highlights continued regional challenges in water and sanitation infrastructure. And neighbouring, Namibia recently reported its first cholera case in nearly a decade within a community near the Angola border – underscoring the interconnected fragility of public health systems across the region.

Seeking sustainable solutions

Amid these pressing challenges, Kaseya articulated Africa CDC’s commitment to fostering innovative and sustainable financing solutions. At the forthcoming World Bank and IMF spring meetings, African health and finance officials will participate in discussions with multilateral development agencies about how they can enhance national resilience and promote self-reliance in managing public health threats. Emphasizing the importance of national ownership, sustainable funding mechanisms, and strengthening local manufacturing capabilities, Kaseya advocated for sustained international engagement and solidarity.

“Health security in Africa is global health security,” Kaseya reiterated.

Image Credits: WHO, Africa CDC, Africa CDC.

Switching from biomass to LPG for cooking, reduced exposures to air pollution, but didn’t lead to measurably significant health gains, a four-country study found.

A four-year, multi-country trial measuring health impacts of reduced indoor air pollution due to the shifting of households from biomass to Liquefied Petroleum Gas (LPG) has yielded  mixed results – defying expectations that reduced indoor air pollution would yield significant health benefits.

The study of 3,200 households in four Asian, African and Latin America countries showed that while the exposure to indoor smoke fell, the expected health gains did not follow.

Despite improvements in air quality so that two-thirds of the households met WHO’s Interim Target 1 for household air pollution, the incidence of severe pneumonia among infants up to one-year “did not differ significantly” when compared to infants in those households that continued to use biomass, investigators with the Household Air Pollution Intervention Network (HAPIN), found.

Nor did the birthweight of newborns rise significantly or incidence  of stunting at 12 months decline – two other early childhood health impacts associated with poor household air quality.

WHO Interim Targets 1 (35 µg/m3) and 2 (25 µg/m3) offer milestones for countries aiming to reduce high household air pollution levels, on the way to the recommended guideline level of 5 µg/m3 of PM2.5.

WHO has set several interim targets to guide countries as they aim to reduce their air pollution levels.

“Everybody kind of expected on the basis of observational studies that now we’re going to see some health benefits from this, even though, you know, a few other experimental studies were saying, well, we’re not seeing it,” Thomas Clasen, the trial’s principal investigator told Health Policy Watch. “So, people are really scratching their heads.” He is an epidemiologist and professor at Emory University.

This also raises a core policy question: should countries push ahead with fossil fuel-heavy LPG or should they instead leapfrog to electric cooking powered by renewable energy like solar?

The HAPIN trial was launched in 2017 and followed 800 pregnant women, 120 older adult women, and 800 infants in poor communities dependent on solid fuels across Guatemala, India, Peru, and Rwanda. One half of the 3200 households were provided access to LPG for 18 months and results were monitored. The trial was funded by the National Institutes of Health (NIH) and the Gates Foundation, among others.

A woman in Guatemala cooks on an LPG stove that she received for free through the HAPIN study.

Mix of positive and negative results

The results showed a mix of positive and negative outcomes.

“Intervention households used LPG exclusively 99.99% of the time,” said Kalpana Balakrishnan of Sri Ramachandra Institute of Higher Education and Research who led the India-leg of the trial. “That answered the question that if you remove the economic barrier, households are willing and able to use a clean energy source, i.e LPG exclusively,” she said.

Average air pollution concentrations in two-thirds of the LPG households declined by half or more – less than 35 µg/m3 (micrograms per cubic meter), Clasen said. The control group that did not use LPG had household air pollution hovering around 70 µg/m3.

“All the health improvements that we expected to see in the intervention compared to the control we did not see,” Balakrishnan told HPW.

Muddying the debate over fuel switching

The World Health Organization (WHO) has also avidly promoted LPG as a clean cooking fuel alternative – despite its climate impacts as a fossil fuel, derived from oil and gas production. These trial results now muddy the debate over whether LPG is still the best option as an “interim” clean fuel choice – or whether countries would be better off promoting electric cooking and heating options, which could reduce indoor emissions even more if they were powered by renewables – and not oil or coal generation.

WHO, for its part, says that the issue will surely be a hot topic of discussion at a major upcoming meeting on air pollution – the Second Global Conference on Air Quality and Health, scheduled for 25-29 March in Cartagena, Colombia.

“WHO is currently reviewing the results from the HAPIN trial and will integrate such evidence in the guidance and support we provide to countries to protect health from household air pollution,” Heather Adair-Rohani who leads the work on air quality, energy and health at WHO headquarters in Geneva told Health Policy Watch in an email response.

“How best to use the results of HAPIN and other key studies to inform decision-making on household energy will be key topic at the upcoming second WHO global conference on air pollution, where WHO, in cooperation with the government of Colombia is calling on countries, cities and organizations to work together to cut the health impacts from air pollution in half by 2040,” she added.

The curious case of lack of health gains despite reduced air pollution 

WHO estimates that around 2.1 billion people worldwide cook on open fires or inefficient stoves that use either kerosene, biomass or coal. Household air pollution was linked to 3.2 million deaths per year in 2020.

And while poor air quality is linked to worsening health, improving air quality in the HAPIN trial did not translate to improved health gains.

A majority of the world’s population still without access to clean cooking energy is in the developing world.

The researchers have one key hypothesis as to why.

“In a community where you have multi-dimensional poverty, if you give a clean fuel intervention for a short time, you may not be in a position to pick up the health benefits that result from it,” Balakrishnan said.

“What you need is to follow them up for a much longer period of time where they continue to use LPG,” she added.

Balakrishnan continued, “The way we have to approach this, … in these poor households, you need a package of interventions to achieve improvement in health.”

Clasen too agreed, “We have to say, well, maybe this isn’t going to be enough by itself to achieve the benefits, the health benefits that you were after.”

Households with the biggest declines in air pollution did see some benefits

One other striking factor is that a small set of households with the biggest concentrations of air pollution before the trial, and thus the biggest declines in pollution from the shift to LPG  – did experience more measurable health impacts.

That could suggest that reductions in air pollution that are larger and more dramatic in order yield more measurable health impacts, at least short term.

“When we look at the folks who had the biggest reductions in exposure, it does look like they’ve benefited…at least reductions in PM, 2.5 and black carbon,” Clasen said.

However, at the lower end of the household air pollution scale, the precise relationship between pollution declines and improvement in health benefits – the so-called “dose-response curve” are not yet well defined, Clasen added

“We do not have well-populated dose-response curves for HAP and [health] outcomes,” he said. “So we cannot rule out health benefits that might have been gained at very low levels of exposure.”

But practically speaking, it’s going to be very difficult to push household concentrations further down in many low-income settings when other environmental and cultural factors such as high rates of smoking, as well as high levels of outdoor air pollution also come into play, he added.

“It’s unlikely that any programmatically delivered HAP intervention is going to achieve lower levels of exposure than what we achieved here, when we had the benefit of free stoves and fuel – and thus nearly exclusive LPG adoption. So from a practical standpoint, we are not likely to improve these health endpoints by getting householders to lower levels of exposure than what we achieved in the trial.”

What do these results mean for policy?

Regardless of the mixed outcomes, Clasen stressed that the results should not be read as a signal to put brakes on transitioning to LPG in developing countries.

LPG is significantly better for climate when compared to biomass because of its lower greenhouse gas emissions.

Even if switching to LPG does not lead to expected health gains in the short run, it still is a significantly efficient fuel. It also lowers greenhouse gas emissions compared to biomass and thus has climate benefits apart from reducing the drudgery involved for women.

LPG’s positive impact on women

“When you’re cooking over a chulha (earthen stove), the drudgery from collecting the firewood or the coal or the gobar (cowdung) to prepare the chulha versus cooking on an LPG…the time it takes…there’s also an opportunity loss because of the time that’s lost in cooking and working around it,” said Neha Saigal, Director of the Gender and Climate Change programme with India-based Asar Social Impact Advisors. Women in the communities Asar works with expressed willingness to use LPG when it was an affordable option.

Cooking on a traditional stove using biomass or coal also directly exposes women to even higher levels of air pollution than might be measured as ambient indoor levels, Saigal said. So shifting may have other health benefits that weren’t captured yet by the HAPIN trial.

An Indian woman cooks with an LPG stove that she received as a participant in the HAPIN study.

Beyond LPG: Staring at limited options

LPG is increasingly affordable and accessible in many developing countries. India, the world’s most populous country, has made tremendous gains in improving LPG access among poor and rural communities though gaps remain. Around 99.8% households in the country now have access to LPG for cooking, according to government data from the year 2021.

And while LPG is a fossil fuel, it is significantly cleaner than biomass. Alternatives to LPG are either not efficient enough for everyday and reliable use, like solar, or require reliable electricity.

Clasen has two reservations about promoting electricity for household cooking in developing countries right now. “One is, is electricity going to do any better than LPG? Right, number two is that [the] electricity is usually generated using fossil fuels, so we may not actually be reducing the climate load by transitioning to electricity unless we also can figure out how to do it renewably,” he said.

Other experts said the quest for better solutions should nonetheless continue.

“I don’t see any other solution at this point of time, at scale other than LPG. But yes, there’s a lot of scope to demonstrate, to pilot with electric cooking, to come up with better chulhas that don’t give out smoke…solar cook stoves,” Saigal of Asar said. “But if we want to support women at the moment, we should make LPG available to them, because that is the thing that’s available now in the market,” she added.

Balakrishnan also raises an ethical question – the poor should not bear the burden of waiting to transition to electric cooking when it is not the norm in urban and well off households. Given that LPG is a viable near-term clean energy choice, the poor too should have access to it right away, she said.

Continuing long-term research will yield more answers 

For now, the HAPIN trial continues to follow children in three locations – Guatemala, India and Rwanda – until they reach the age of five. They want to see if delivering their mothers LPG access for 18 months has had any long-term health benefits that might become clear only later, like neurocognitive development or development of a child’s mental abilities.

“It could be quite compelling from a policymaker standpoint,” Clasen said.

Image Credits: WHO/Adobe Stock/Dennis Wegewijs, WHO, Guatemala HAPIN team, T20 Policy Brief, July 2023, India HAPIN team.

Power outages are common in Kashmiri hospital, particularly in winter.

BARAMULLA, India – The biting cold seeped through the cracks of the health facility in Tangmarg in northern Kashmir as 23-year-old Madiha* wrapped her shawl tighter around her shoulders. She had barely stepped inside when the lights flickered—and then went out.

A tense silence fell over the dimly lit corridor before the deep, guttural roar of the backup diesel generator filled the air. Thick, acrid smoke curled into the room, stinging her nose and leaving a metallic taste on her tongue. Patients huddled together, their breath visible in the freezing air, while nurses rushed around under the weak glow of emergency lights.

Madiha’s experience is an everyday crisis for health facilities across Kashmir, in India’s northernmost region. A predominantly Muslim region, it is administered by India as a union territory – although it has been the subject of a dispute with Pakistan since 1947.

Across the region, hospitals battle chronic electricity shortages that have increased reliance on polluting diesel generators that spew toxic emissions into already pollution-choked air. Poor waste management in rural hospitals compounds problems.

These systemic failures, which get worsen every winter, not only cripple healthcare services but also fuel respiratory illnesses and waterborne diseases, turning hospitals from places of healing into sources of environmental and public health hazards.

Climate change reduces hydropower 

“We rely on diesel generators, but they often fail,” said a doctor who asked not to be named, at a hospital in Baramulla where daily power cuts often stretch beyond five hours, leaving critical patients in distress.

“For patients with respiratory illnesses, the fumes and the lack of consistent oxygen supply make it unbearable.”

Some 112 Primary Health Centers (PHCs) and 710 sub-centers across the territory of Jammu and Kashmir (J&K) operate without electricity, according to official data

But the situation on the ground is far worse, according to residents who report frequent and prolonged blackouts that force hospitals to depend on diesel generators. 

J&K’s electricity derives from hydropower, and a combination of climate change and neglect has reduced the region’s supply – particularly in winter where lower rainfall, drier conditions and glaciers freezing dramatically reduce water levels in rivers.

During the winter of 2024, hydropower generation plummeted by 65% to a mere 250 MW – a stark decline from the region’s capacity of 1,140 MW. The shortfall left hospitals scrambling to keep the lights on, often at the cost of public health.

“We have endured power outages lasting up to eight hours. This is particularly dangerous for healthcare,” said policy expert Abrar Dar, speaking to Health Policy Watch in Srinagar. “Generators have a load limit, and exceeding that capacity can disrupt critical medical services.”

Dar also pointed out the stark disparity in electricity access across India. I often stay in Delhi, where 24/7 power is a given. Why don’t we have the same in Jammu and Kashmir?”

Despite spending ₹55,254 crore (over $6,3 million) on power purchases over the last decade, the region continues to face chronic shortages. 

While only 3.8% of healthcare facilities in India lack electricity, the number is 10.7% in Kashmir, highlighting central government neglect and the region’s severe healthcare infrastructure crisis.

Kashmir sells hydropower 

For rural Kashmiris, power shortages are a harsh, generational reality. Ishtiyaq Wani, 64, has lived with it his entire life.

“For 60 years, I’ve heard on the radio how fast the world is moving,” Wani said. “Decades ago, I heard about people going to the moon, yet despite Kashmir having its own hydropower projects, we still have to beg for electricity.”

Kashmir’s 13 hydropower projects have generated 48,808 million units (MU) of energy over the last decade. But during the bleak winter months, the regional power utility, Jammu and Kashmir State Power Development Corporation (JKSPDC), is forced to buy electricity from private companies.

It has been unable to recoup these costs from consumers so JKSPDC is forced to sell up to half the electricity it generates in the summer to private companies to recover its winter costs.

“J&K has vast hydropower potential, but most of our electricity is sent to the national grid or sold to other states,” explained social activist Muhjeeb Wani from Budgam. 

The central government’s refusal to fund three major hydropower projects – Kiru, Ratle, and Kwar – in the 2025-26 financial year has further delayed much-needed infrastructure.

Diesel generators worsen air pollution

A hospital generator in Kashmir

Diesel generators, used as a lifeline during blackouts, are also major contributor to air pollution including black carbon, further endangering public health.

“Thousands die each year from pollution, yet despite having our own hydropower projects, we continue to suffer from electricity shortages,” said Mukhtar*, a 24-year-old from North Kashmir, frustration evident in his voice. “Hospitals, which are supposed to heal people, are instead worsening the climate crisis.”

According to the World Health Organization, air pollution-related death rates in India are approximately 140 per 100,000 people. Reports suggest that 10,000 people die each year in J&K due to PM2.5 exposure.

Beyond electricity shortages, improper medical waste disposal poses another health hazard. Many rural hospitals dump hazardous biomedical waste in open areas, contaminating drinking water and farmland.

“Hospital waste is thrown into streams, and we’re forced to drink polluted water,” said Mukhtar.

A 2019–2020 Jammu and Kashmir government report found that only 35.6% of the 1,518.91 metric tons of solid waste generated daily was treated. Although this figure improved to 63.1% by 2020–21, over 500 tons of garbage remain untreated every day. 

Last September and October, Kashmir reported over 130 cases of Hepatitis, highlighting a growing public health crisis. 

“Water pollution has multiple causes, but hospital waste should never be dumped in open areas,” Dr Shazaib Mir told Health Policy Watch. “It must be safely disposed of, or incinerated. Waterborne diseases claim millions of lives every year.”

In a 2017 study of 500 households in North Kashmir, a third of the 3,185 individuals surveyed suffered from waterborne diseases, including diarrhea, Hepatitis A and gastrointestinal infections. 

“These illnesses are only part of the struggle,” says Mukhtar. “In winter, Kashmir’s crumbling healthcare system collides with another deadly reality—impassable roads.”

In winter, healthcare is a challenge

On paper, J&K has a network of government-run hospitals and health centers. But in reality, harsh winters between November and February turn medical emergencies into life-or-death struggles.

“If an emergency strikes in winter, we have no choice but to carry the patient on our shoulders, walking for eight kilometers,” says Nasreena*, a heart patient from Nilsar, a remote town in Kashmir.

We locals have somehow adapted to these challenges, but what if a tourist has a medical emergency? What will they do?” 

A record 2.95 million tourists visited J&K in 2024. In critical cases, patients have to walk over eight kilometers for proper care, which can turn fatal in sub-zero temperatures.

On 10 March, a helicopter landed in Tulail, a snowbound village, to rescue 27 stranded passengers including a pregnant woman in urgent need of medical attention. But such interventions are rare.

For most Kashmiris, winter isolation means making treacherous journeys on foot, often with tragic consequences. In Baramulla, 54-year-old Mumtaza* suffered a heart attack one freezing night. With no ambulance and no accessible roads, her family carried her for six kilometers through knee-deep snow. By the time they reached the hospital, she had passed away.

“My aunt could have survived if help had reached us,” says her niece, Mehnaaz*. “Instead, we walked for hours, and she died on the way.”

Official data states that 11.5% of healthcare facilities in Jammu and Kashmir remain inaccessible by all-weather roads, but locals insist the reality is far worse. Without urgent investment in road infrastructure and emergency transport, more lives will continue to be lost—not just to illness, but to the sheer inability to reach medical care in time.

Patients crowd a pharmacy in Kashmir to buy medicine.

Starved of investment

At the heart of Kashmir’s healthcare crisis is a severe lack of investment in infrastructure. While India has steadily increased healthcare spending in other regions in recent years, development in Jammu & Kashmir continues to lag, with underfunded hospitals, poor road networks, and an unreliable electricity supply exacerbating the situation.

According to the National Health Profile 2023, India spends only 2.5% of its GDP on healthcare, one of the lowest rates of major economies 

This chronic underfunding is reflected in the state of health infrastructure, where rural health facilities lack electricity, medical equipment, and essential drugs. 

The situation is worse in J&K, where there was a slight dip in the health budget allocation for 2024-25, according to the Jammu and Kashmir Economic Survey (from ₹8,362.28 crore in 2023-24 to ₹8,333.45 crore).

The healthcare sector’s struggles are also reflected in the shortage of health workers. J&K faced a shortfall of 700 doctors and specialists at Primary Health Centers (PHCs) and Community Health Centers (CHCs) in 2022-23, according to a health ministry report. In many remote areas, a single doctor is responsible for thousands of patients, making access to timely medical care nearly impossible.

For Kashmiris, these systemic failures translate into daily struggles – from mothers giving birth in candle-lit rooms to elderly patients gasping for air in smoke-filled wards, and families carrying their sick along snowbound mountain trails. 

Experts warn that without a significant increase in healthcare investment, improved road connectivity, and a reliable power supply, thousands more will continue to bear the brunt of a broken system – year after year.

*Some patients asked not to be identified by their full names.

Image Credits: Arsalan Bukhari.

USAID
USAID staff offload emergency supplies.

Secretary of State Marco Rubio announced that 83% of US international aid programs were “canceled” hours before a federal district judge ruled that the administration’s actions were an overreach of the Executive branch’s power. At risk are thousands of lifesaving humanitarian programs.

In a refugee camp in Bangladesh, 500,000 Rohynga children depend on food treatment aid for their survival. One-year-old Mariam recovered from severe malnutrition after treatment in a UNICEF camp, but now her mother fears the clinic would shutter. 

“If you stop providing us with this therapeutic food, my child could die,” she told UNICEF.  

Thousands of US Agency for International Development (USAID) contracts have been terminated, after Secretary of State Marco Rubio signaled that the six-week review of the aid agency is “officially” complete. The remaining programs overseen by the six-decade-old USAID will now be part of the State Department, Rubio said.

Late Monday, a federal district judge said that the Trump administration’s halt of foreign assistance overstepped the Executive branch’s authority. The judge ordered the administration to pay USAID partners for work already completed before 13 February, but stopped short of restoring the more than 10,000 contracts the administration has canceled.

Separation of powers

A vaccination site in South Africa co-sponsored by USAID.

The judge ruled that the administration could not withhold the billions of dollars Congress had already approved for foreign aid, saying the president does not have “unbounded power” in foreign affairs. 

“The Executive not only claims his constitutional authority to determine how to spend appropriated funds, but usurps Congress’s exclusive authority to dictate whether the funds should be spent in the first place,” Washington DC district’s Judge Amir Ali said.

Ali ruled in his preliminary injunction late Monday that Trump could not ignore the $60 billion Congress already allocated for foreign assistance to USAID. Congress alone has the power to allocate funding under the US Constitution. 

“The constitutional power over whether to spend foreign aid is not the President’s own — and it is Congress’s own,” said Ali. In response to a suit filed by the AIDS Vaccine Advocacy Coalition (AVAC), the Journalism Development Network, and the Global Health Council, Ali ordered the administration to pay aid groups the money owed for work completed up to 13 February, at a pace of at least 300 back payments a day. 

But he declined to restore contracts the administration canceled, saying it was up to the Trump administration to decide which organizations could win contracts. 

Ali’s ruling came after the Supreme Court cleared the way for a lower court to rule on the aid freeze.

Trump ‘is not king’

“Today’s decision affirms a basic principle of our Constitution: the president is not a king,” said Lauren Bateman, an attorney with Public Citizen Litigation Group and lead counsel representing the two organizations filing suit, in a statement.

“But we are painfully aware that, without unwinding the mass termination of foreign assistance awards, winning on the constitutional issues does not avert the humanitarian disaster caused by the Trump administration’s freeze on foreign assistance. And it does not undo the damage that the freeze has already inflicted on millions of vulnerable people across the world. Deaths will continue to mount.

“While the courts have an important role to play in standing up for the rule of law, Americans need more than just the courts. We need Congress, which has always supported foreign aid on a bipartisan basis, to assert itself.”

Whether Congress will act is yet to be seen, especially as the deadline to fund the federal government  looms. The House passed a procedural measure for its funding bill Tuesday along party lines, which critics say is a “blank check” for the Trump administration’s agenda.  

Republican members of congress have voiced support for a narrower definition of US’s involvement in foreign development programs, and support Elon Musk’s Department of Government Efficiency’s (DOGE) efforts to cut back the federal government. 

Earlier in February, the House Foreign Affairs Committee held a hearing titled “the USAID Betrayal,” where chair Brian Mast (R-FL) argued that USAID programs “hurt America’s standing around the globe, and I think the fact is clear that America would have been better off if your money had been simply thrown into a fireplace.”

‘Reform’ completed 

Rubio’s declaration that thousands of aid contracts were “officially” canceled came after the Trump administration’s six-week battle to gut USAID, calling the move an “overdue and historic reform.” His post was one of the few public comments on the swift dismantling of US policy of soft power and aid in developing countries.

“The 5200 contracts that are now cancelled spent tens of billions of dollars in ways that did not serve, (and in some cases even harmed), the core national interests of the United States,” said Rubio on X.

He said the remaining 1,000 contracts would be administered directly by the State Department. 

The Trump administration has made misleading claims that millions of taxpayer dollars were being used for diversity, equity, and inclusion (DEI) initiatives. Funding for many of these activities came through the State Department not USAID, at the request of embassies, according to independent fact checkers.

“It’s been run by a bunch of radical lunatics,” Trump said last month. “And we’re going to get them out.” But the dismantling of USAID has meant a freeze on malaria, HIV, and tuberculosis aid, which combined protect millions of people in Africa, Latin America, and Southeast Asia from the leading infectious diseases. 

“Under President Trump, the waste, fraud, and abuse ENDS NOW,” the White House said in a February statement.

Humanitarian groups offer dire warnings 

unicef rohingya usaid malnutrition
UNICEF personnel measure a Rohingya child’s arm for signs of malnutrition.

Mariam and her mother are among thousands of Rohingya refugees at risk of malnutrition in the Cox’s Bazar camp, said Rana Flowers, UNICEF representative in Bangladesh.

“Children in the world’s largest refugee camp are experiencing the worst levels of malnutrition since the massive displacement that occurred in 2017,” she said at a press briefing in Geneva on Tuesday.

Other UN organizations echoed her warning that cuts to humanitarian aid would result in further devastation.

The UN Commmision on Human Rights (UNCHR) has already shut down a US-funded program that worked with torture victims and families of disappeared persons. The US represented more than 40% of UNHCR’s budget in Colombia, meaning the agency’s work of “resolving” and “pre-empting” crises is threatened, said Ravina Shamdasani, UNCHR Chief Spokesperson at the Geneva press conference.

The agency received USAID suspension letters for all projects in Equatorial Guinea, Iraq and Ukraine, as well as Bangladesh, Colombia, Ethiopia and Peru.

‘No replacement’ for USAID

Rana Flowers, UNICEF representative in Bangladesh, speaking about the 500,000 children living in the world’s largest refugee camp.

Although the US granted a waiver for UNICEF’s work to prevent malnutrition in refugee camps, there is no guarantee that the agency will be able to continue using the therapeutic food to treat and cure sick children with acute malnutrition.

Flowers noted that the agency needs both the waiver and actual funding to continue the work. Funding for malnutrition treatments runs out in June. Unless additional funding is secured, only half of refugee Rohingya children will have access to treatment this year, Flowers warned. 

Without access to treatment, up to 7,000 children are at risk of severe malnutrition. UNICEF expects an increase in morbidity and mortality in these camps. 

“There’s no replacement for the valuable partnership with the United States,” said Flowers.

“Until now, this community has survived thanks to the solidarity of the international humanitarian community,” she said. “But today, an aid funding crisis risks becoming a child survival crisis.” 

Additional reporting by Elaine Fletcher.

Image Credits: USAID Press Office, USAID, UNICEF/Njiokiktjien.

Françoise Moudouthe, Chief Executive Officer of the African Women’s Development Fund,
Françoise Moudouthe, Chief Executive Officer of the African Women’s Development Fund,

“The poison of patriarchy is back and is back with a vengeance,” United Nations (UN) Secretary-General António Guterres told the opening of the annual session of the Commission on the Status of Women (CSW) at the UN in New York on Monday.

The CSW takes place amid a major global backlash against women’s rights, from the Taliban banning Afghan women from public life to the Trump administration in the United States pushing back against “diversity, equity and inclusion” (DEI) which has resulted in cuts to research on women’s health

“Misogyny is on the rise, and so, violence and discrimination,” said Sima Bahous, who heads UN Women, noting that “domestic and ODA [official development assistance] allocations to gender equality remain woefully inadequate and, in some cases, are being cut altogether”. 

Declaration passed despite US, Russian objections

The CSW’s political declaration was adopted by consensus on Monday. And despite earlier reports that the US and Russia had tried to purge a clause that encouraged member states from nominating women candidates for the UN Secretary-General position and  President of the General Assembly, that clause survived.

So did commitments to “gender equality and the empowerment of all women and girls”, and the “accelerated implementation” of the Beijing Declaration and Platform for Action, the first global roadmap for gender equality that was adopted 30 years ago.

Bahous also commended the 159 member states that have affirmed their support for the Beijing Declaration in national reports.

Despite the backlash, there has also been progress in the past 30 years, she noted: “Today, more girls are in school. More women are in parliaments, in boardrooms, in the judiciary. Maternal mortality has fallen. Legal barriers have been dismantled. Policies to protect and advance women’s rights are advancing. Violence against women and girls is widely recognized as a global scourge.” 

‘Calculated cut’ to funds

Françoise Moudouthe, Chief Executive Officer of the African Women’s Development Fund, told the opening plenary that “the decision by several governments and philanthropic actors to cut funding for gender equality in the past few years is a calculated blow to women’s access to education, healthcare, economic independence, political participation and bodily autonomy”. 

“The recent funding cuts by just two governments and two private philanthropic donors to women’s rights organisations were recently estimated to around $730 million per year,” she added.

“We must immediately commit to protecting protecting gender equality for all, not with words but with resources,” Moudouthe stressed.

Bahous declared that: “We, the champions of gender equality, are not afraid of the pushback. We have faced it before. We have not backed down. And we will not back down.”

The proportion of women killed in wars had doubled over the past year alone, added Bahous, pointing to women’s and girls’ rights being “systematically stripping away” by climate change and conflicts in Afghanistan, the Democratic Republic of Congo (DRC), Palestine, Gaza, Haiti, Myanmar, Sudan and Ukraine.

Call for sanctions on Taliban

Meanwhile, at the UN Security Council meeting happening at the same time, Afghan lawyer Azadah Raz Mohammad urged the body to impose sanctions on all Taliban leaders who have committed human rights violations against Afghan women and girls, and not to lift sanctions, including travel bans, on those who are guilty of such crimes.  

“If the people of Afghanistan had been able to hold the Taliban accountable in 2001 and earlier, perhaps we would not have witnessed the Taliban’s violent return to power 20 years later,” Mohammad said, concluding: “If impunity is the disease, accountability is the antidote.”  

She also urged all member states to assist the International Criminal Court to pursue charges against all senior Taliban leaders who have committed acts of “gender persecution and other crimes against humanity, and war crimes” in Afghanistan since 2003.

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.