Kenyan women at a family planning clinic.

Global health organisations have reacted with anger to the new US foreign aid policy, which prohibits all aid recipients, bar military, from performing or promoting abortion, “gender ideology”, or “diversity, equity and inclusion” (DEI).

“Catastrophic”, “bullying”, “draconian” and “ideologically driven” – are some of their reactions to the Promoting Human Flourishing in Foreign Assistance (PHFFA) policy, announced by US Vice-President JD Vance at an anti-abortion event last Friday evening.

The policy’s three parts were published in the Federal Register on Tuesday as Protecting Life in Foreign Assistance, Combating Gender Ideology in Foreign Assistance and Combating Discriminatory Equity Ideology in Foreign Assistance Rules.

The new rules apply to all foreign and US NGOs and “international organisations”, including multilateral UN agencies still funded by the US and bodies such as the Global Fund to Fight AIDS, TB and Malaria.

However, in countries that allow abortion, governments and parastatals (government agencies) will need to place any US funds in “a segregated account” to ensure they’re not used for abortions and related activities.

Governments and parastatals “may” also be required to agree that they won’t use US funds to promote or engage in “gender ideology” or DEI.

The US State Department defines “gender ideology” activities as those that provide or promote “sex rejecting procedures” (defined broadly to include puberty blockers, hormones, surgeries); promote or counsel social transition; use materials that discuss changing one’s sex or pronoun usage not aligned with biological sex; lobby foreign governments on gender identity issues; and support drag queen workshops, performances, or similar activities”.

Aid recipients are also compelled to agree to US officials visiting their offices unannounced to inspect their documents and activities, and to speak to people receiving their services. This is potentially a violation of patient confidentiality.

Imposing ‘extremist ideology’

Since 1984, successive Republican governments have imposed a “Global Gag Rule” (also known as the Mexico City Policy) on foreign NGOs receiving global health aid, barring them from using this money – or even money they have raised from other sources – for any abortion-related activities, including referrals.

However, the second Trump administration is the first to extend this to all non-military foreign assistance, including humanitarian assistance, and to widen the scope to include US NGOs, international organisations and – potentially – governments.

“Bullying countries into complying with anti-rights and extremist ideology is despicable and unacceptable. The imperialist goals of this administration are on full display in these conditions to foreign assistance,” Anu Kumar, CEO of the global reproductive justice organisation, Ipas, told a media briefing this week.

In 2024, $39.8 billion in US foreign aid was dispensed over 160 countries, with the largest share (41%) going to multilateral agencies, according to KFF.

“This is tens of billions more than the amount of global health assistance subject to the policy under the first Trump administration’s previously expanded policy ($7.3 billion in 2020),” notes KFF.

This “catastrophic expansion” is going to be especially harmful to “women, young people, girls and LGBTQI+ people”, added Ipas senior researcher Jamie Vernaelde.

“There is an agenda here from the US government to push these ideologies across to other countries, both through direct government-to-government funding, but also forcing multilateral organisations to be subject to the ideology of one specific country.”

Impact on Kenya

The bilateral Memorandums of Understanding (MOU) that the US has signed with 15 African countries as part of its “America First Global Health Strategy” all contain a clause compelling countries to comply with the Global Gag Rule.

“What we’ve realised is this inclusion of the Global Gag Rule in the MOUs was basically a Trojan horse, in the sense that now the governments have signed, they are obligated to implement these expanded conditions, for example, on gender ideology,” said Ipas’s Kenya director, Dr Musoba Kitui.

Kitui said that 40,000 health workers had already lost their jobs in his country since the closure of the US Agency for International Development (USAID), leading to the “weakening of the health system”.

Many African governments “are very, very desperate” to inject resources into their health systems since the closure of USAID, and were willing to sign bilateral MOUs with the US, despite some of the unfavourable conditions, said Kitui.

Kenya’s MOU would be complex to implement, and there is “no way the US can monitor compliance without seeing patient records,” added Kitui, highlighting a concern about patient privacy which has resulted in the MOU being challenged in court.

However, “this MOU grants US personnel diplomatic immunity, insulating them from any local courts against judicial processes for any violations of data privacy, or even crippling the health system for that matter”, he added.

“Sexual and reproductive health is not a diplomatic bargaining chip. It’s a fundamental human right. Essential health care services must be separate from political agendas. What is really important is to protect the progress that we have made over the years, including in countries like Kenya,” Kitui stressed.

Impact on humanitarian aid

South Sudanese women survivors of violence shared their stories with a visiting UN delegation. The narrow redefinition of US global aid will affect survivors of gender-based violence who need access to rape kits and emergency contraception.

Dr Jean-Claude Mulunda, who heads Ipas work in the Democratic Republic of Congo (DRC), said that his organisation assisted displaced people in camps with family planning services, abortion care and also supports survivors of gender-based violence (GBV). 

With the demise of USAID, “rape kits” for GBV survivors containing medicine to protect women and girls against sexually transmitted infections and pregnancy are no longer available.

“Ipas is trying, with our limited funds, to buy unit-by-unit, the different medicines in these kits,” said Mulunda. “Many women who are victims of rape can’t access abortion care, even though the country has signed the Maputo Protocol which allows access to abortion in case of rape.” 

The more onerous aid conditions are going to make it even harder for displaced women to access sexual and reproductive services.

“The risk of unsafe abortion is elevated in humanitarian settings where it’s even harder for people to access medical services,” warned Médecins Sans Frontières (MSF) in its reaction to the new policy.

“In 2023, MSF provided more than 31,000 consultations for post-abortion care, most of which were due to complications related to unsafe abortion. With the reinstatement of the Global Gag Rule, MSF expects these already troubling numbers to increase.”

The new policy, PHFFA, “escalates a pattern established across both Trump administrations: the systematic subordination of scientific evidence and patient needs to ideological and political objectives,” added MSF. 

“Versions of the Global Gag Rule have been introduced by Republican administrations since 1984, and extensive research has repeatedly documented that the policy disrupts health services and causes cascading adverse health outcomes in low- and middle-income countries, with the chilling impact enduring even when the policy has been rescinded,” MSF noted.

MSF added that the State Department’s definitions of “gender ideology” and “discriminatory equity ideology” are so broad “that it is likely to result in barring or limiting access to essential health services for LGBTQIA+ individuals, women and girls, racial and ethnic minorities, and other marginalized groups”. 

‘Abdication of decency’

US Vice President JD Vance addressing the March for Life last Friday, where he announced the new policy.

“President Trump and his anti-abortion administration would rather let people starve to death in the wake of famine and war than let anyone in the world get an abortion – or even receive information about it,” said Rachana Desai Martin, chief US program officer at the Center for Reproductive Rights. 

“People are already dying because of this administration’s slashing of foreign assistance. Now, they’re making it harder for doctors and aid workers to provide food, water, and lifesaving medical care. This isn’t about saving lives – it’s a stunning abdication of basic human decency,” Martin added.

“Trump’s expansion [of the Global Gag Rule] continues on a path of instrumentalising those most marginalised. It marks increasing attempts to capture global health and human rights with a deeply regressive act of imperialism masquerading as foreign policy,” said Mina Barling, International Planned Parenthood Federation’s global director of external relations. 

“This is yet another attack on national sovereignty and colonial intervention through the curtailing of sexual and reproductive rights.”

“The dismantling of USAID has already caused widespread harm: more than 45 million women and girls have lost access to contraceptive care and clinics around the world have been forced to close,” said Marieke van der Plas, executive director of the Dutch reproductive rights organisation, Rutgers.

“Now, the Trump administration is further reshaping global health policy through new government agreements that embed ideological conditions and deepen political control.”

The Senate Foreign Relations Democrats said in a statement: “By blocking US funding to any entity that does not conform to his extreme ideological agenda, the administration is exporting MAGA culture wars overseas and turning lifesaving aid into a political tool. 

“This order goes far beyond anything we’ve seen before. It will shrink global resources to fight disease, respond to humanitarian crises and protect women and girls from violence, while forcing many of our trusted partners to shut their doors or betray their missions. In doing so, it also leaves Americans more vulnerable to infectious diseases and health threats that do not respect borders.”

Image Credits: saac Billy/ UN Photo, KFF.

Flagship UN report finds irreversible damage to global water systems affects three-quarters of the global population, threatens food security and thrusts the world into a new era of the water crisis.

The world has entered the era of “global water bankruptcy” as water systems relied on by six billion people, and half of the world’s food production, are pushed beyond the point of recovery, a United Nations (UN) report has found.

The report marks the first time UN scientists have declared water systems “bankrupt” rather than “stressed or “in crisis”, a distinction that denotes irreversible damage to natural water systems, as opposed to acute, time-limited shortages due to factors like weather, high demand or economic shocks.

“This report tells an uncomfortable truth: many regions are living beyond their hydrological means, and many critical water systems are already bankrupt,” said Kaveh Madani, director of the UN University’s Institute for Water, Environment and Health and lead author of the report.

“If we continue to manage these failures as temporary crises with short-term fixes, we will only deepen the ecological damage and fuel social conflicts,” Madani said. “We must act because water bankruptcy is a justice and security issue. The cost of the hydrological overshoot that the world is facing falls disproportionately on those who can least afford it.”

The UN report arrived ahead of high-level meetings in Dakar, Senegal, this week to prepare the agenda for the 2026 UN Water Conference, set for December in the UAE. It calls on member states to formally recognise water bankruptcy, establish global monitoring frameworks and position water investments as fundamental to achieving climate, biodiversity and food security targets.

This year’s summit is only the second major international meeting on water governance this century, following a 2023 summit at UN headquarters in New York. The only other global water conference in history was held in Mar del Plata, Argentina, in 1977.

“Declaring bankruptcy is not about giving up, it is about starting fresh. By acknowledging the reality of water bankruptcy, we can finally make the hard choices that will protect people, economies, and ecosystems,” Madani said. “The longer we delay, the deeper the deficit grows.”

‘Day Zero’ threatens major cities

The world’s third largest lake, the Aral Sea, lying between Kazakhstan and Uzbekistan in 1989 (left) and in 2025 (right).

The UN report draws on satellite data, hydrological modelling and over 300 case studies to document the scale of water loss.

More than half of the world’s large lakes have lost water since the early 1990s, over 30% of glacier mass since 1970 has disappeared in certain regions, while about 410 million hectares of natural wetlands—a land mass nearly equal to that of the European Union—have been destroyed over the past five decades.

“Surface waters are shrinking. Those are our checking accounts that get renewed every year, that nature is kind enough and generous enough to deposit some budget, give us some income,” Madani explained. “It is normal to go to the savings account and buy resilience for the dry years. But what we are seeing around the world is that the savings accounts are also draining – we are exhausting them.”

The Middle East, North Africa, South Asian and parts of the American Southwest face the most severe threat as high water stress collides with extreme vulnerability to climate change. Over 1.42 billion people, including 450 million children, already live in conditions of high or extremely high water vulnerability, according to UN Water data.

Water scarcity has been a major driver of public outrage at Iran’s regime throughout the recent wave of protests. After six years of drought, reservoirs around its capital, Tehran, are on the brink of the next “Day Zero” event. / Satellite image: Institute for the Study of War.

For some of the world’s largest cities, the crisis has already arrived. Metropolises around the globe, from Cape Town to Sao Paolo and Tehran, have already faced their first “Day Zero” emergencies – events where water supplies for a city are near complete depletion. Kabul, meanwhile, is on the brink of becoming the first major city globally to run out of water.

While cities survived, these first “Day Zero” events are warning shots, and many – particularly the urban poor – continue to live with the consequences, the UN warned.

“Emergency measures—severe restrictions, tariff changes, rapid drilling of new wells, reliance on tanker supplies, and behavioural campaigns—helped some cities narrowly avoid a complete shutdown of taps,” the report found.

“Yet in many of these places, the underlying aquifers, reservoirs and catchments remain degraded, and poorer neighbourhoods continue to live with intermittent service, tanker dependence, and high water costs long after the media attention has moved on.” 

Half the world’s 100 largest cities experience high water stress, while 38 – including Beijing, New York, Delhi, Los Angeles and Rio de Janeiro – face “extremely high stress” levels, according to a separate analysis published by Watershed Investigations this week.

Another study published this year by the University of Utrecht, analysing 21 global water scarcity hot spots, found that hydroclimatic change – long-term changes in water cycles driven by climate change – was cited in 49% of case studies, but typically was not the sole driver of scarcity, operating alongside population growth (31% of cases), agricultural overuse (77%), industrial demand (30%) and municipal consumption (46%).

Disease and displacement

Water access is a fundamental determinant of health, yet nearly 2.2 billion people lack safely managed drinking water, while 3.5 billion lack safely managed sanitation, according to WHO figures. 

These gaps expose populations to cholera, typhoid, polio, dysentery, hepatitis A and diarrhoea. Waterborne diseases and inadequate water supplies kill an estimated 3.5 million people annually, according to UN Water. WHO research estimates that 900 children under five per day die from diarrheal diseases caused by unsafe water.  That is one child every two minutes, adding up to 328,500 deaths every year.

About four billion people—nearly two-thirds of the global population—face severe water scarcity for at least one month every year, forcing communities to use water contaminated with agricultural runoff, industrial waste and untreated sewage for basic health activities such as handwashing and bathing. This amplifies the breeding grounds for infectious waterborne disease spread and raises risks of poisoning from chemicals like lead or arsenic.

Water scarcity also drives displacement, which cascades into health crises as populations move into areas with inadequate sanitation, limited healthcare and overcrowded conditions that accelerate health risks. Over 700 million people are projected to be displaced by water scarcity by 2030, according to UNICEF.

“Bankruptcy management requires honesty, courage, and political will,” Madani said. “We cannot rebuild vanished glaciers or reinflate acutely compacted aquifers. But we can prevent further loss of our remaining natural capital, and redesign institutions to live within new hydrological limits.”

Water-driven conflicts rise

Water-related violence has nearly doubled since 2022, rising from 235 incidents to 419 in 2024, according to Water Conflict Chronology, a database updated this week by the Pacific Institute that tracks water-driven violence throughout history.

The dataset contains 2,757 conflicts dating back to a dispute in ancient Sumeria over water and irrigation that led to nearly a century of war in 2500BC. The latest incident added documents of residents punching and beating firefighters in Manila, Philippines, blaming them for a lack of water.

Water has increasingly been a target in major wars, despite Article 54 of the Geneva Convention classifying attacks or destruction of water infrastructure or supplies necessary for civilian survival as a war crime.

Recent examples include Israel’s systematic destruction of Gaza’s water systems and desalination plants, Russia targeting hydropower dams in Ukraine, and tensions over the Indus River treaty between India and Pakistan, the report found.

Water Conflict Chronology’s tracker lists nearly 3,000 wars over water since 2500BC.

Oxfam’s water security lead, Joanna Trevor, told the Guardian that her team has observed “an increase in localised conflicts over water due to climate change and water insecurity” as competition for dwindling reserves intensifies.

“In East Africa and the Sahel, water is becoming increasingly insecure, and people are moving into new areas to access water, which in itself can trigger competition and conflict with the host population,” Trevor said.

UNICEF estimates that by 2040, roughly one in four children—about 450 million—will live in areas of extremely high water stress.

“Water bankruptcy is becoming a driver of fragility, displacement and conflict,” said Tshilidzi Marwala, UN Under-Secretary-General. “Managing it fairly is now central to maintaining peace, stability and social cohesion.”

Food systems dry up

Total freshwater withdrawals for agriculture, industry and domestic uses across the globe from 1900 to 2010.

Three billion people and more than half of global food production are concentrated in areas where total water storage is already declining or unstable, according to the report.

With agriculture accounting for an estimated 72% of global freshwater withdrawals, the report’s concern is echoed by recent research by the World Resources Institute (WRI), which found 25% of the world’s crops are grown in areas where water supply is highly stressed or unreliable.

“One out of every 11 people in the world grapples with hunger,” WRI found. “A hidden and growing driver is lack of water.”

As water stress soars, the world will need to produce 56% more food calories in 2050 than it did in 2010 to feed a projected population boom to 10 billion people.

Yet current production is already under threat: one-third of rice, wheat and corn produced globally—which provide more than half of global food calories—is grown in water-stressed regions, while irrigation water demand is forecast to increase 16% over the next two decades due to warming temperatures, according to WRI.

“We need to decouple growth from water,” Madani said. “We need to move away from the asumption that economic prosperit requires ever-increasing water withdrawals – the problem that has got us in this situation.”

Just 10 countries produce 72% of the world’s irrigated crops, with two-thirds of that production facing high to extremely high water stress. India, the world’s largest rice exporter, is losing up to 30 centimeters of groundwater per year in some regions, with depletion rates projected to triple by 2080.

Over 170 million hectares of irrigated cropland—equivalent to the combined land area of France, Spain, Germany and Italy—are under high or very high water stress. An additional 106 million hectares have been degraded by salinisation, the UN report found.

“Millions of farmers are trying to grow more food from shrinking, polluted or disappearing water sources,” Madani said. “Without rapid transitions toward water-smart agriculture, water bankruptcy will spread rapidly.”

“Despite its warnings, the report is not a statement of hopelessness,” he concluded. “It is a call for honesty, realism, and transformation.”

Image Credits: Art Poskanzer, Institute for the Study of War , Pacific Institute.

WHO flags
The US accused the WHO of “holding hostage” the American flag that once flew outside the Organization’s Geneva headquarters (seen here in 2025).

A dispute over an American flag has become symbolic of the bitter public dispute between the US and the World Health Organization (WHO) after the US withdrew from the organization on 22 January.

In a joint statement by Secretary of State Marco Rubio and Secretary of Health and Human Services Robert F Kennedy Jr on the termination of US membership of the WHO, they accused the organization of keeping the American flag that hung outside its Geneva headquarters captive.

“Even on our way out of the organization, the WHO tarnished and trashed everything that America has done for it. The WHO refuses to hand over the American flag that hung in front of it, arguing it has not approved our withdrawal and, in fact, claims that we owe it compensation. From our days as its primary founder, primary financial backer, and primary champion until now, our final day, the insults to America continue.

“We will get our flag back for the Americans who died alone in nursing homes, the small businesses devastated by WHO-driven restrictions, and the American lives shattered by this organization’s inactivity,” the statement said.

A day after the official withdrawal, the State Department declared victory, posting: “Under @POTUS leadership, the @StateDept and @HHSGov have secured its return, now safely held by U.S. Marines @usmissiongeneva, and on its way back to USA.”

The dispute over the flag underscores broader and long-simmering tensions between the Trump administration and the WHO, particularly over the Organization’s handling of the COVID-19 pandemic.

US still owes WHO $260.6 million

The US’s highest-ranking health officials, including National Institutes of Health director Dr Jay Bhattacharya, rose to prominence during the pandemic for their criticism of COVID-19 policies, tapping into widespread public anger over restrictions, school closures, and vaccine mandates.

In the view of current US leadership, the WHO is an organization “beyond repair.”

Instead, the Trump administration has begun pursuing a series of bilateral agreements with 14 sub-Saharan African countries, aiming to recreate aspects of the WHO’s multilateral system for pooling scientific and public health data.

But according to global health policy experts at Georgetown University, Sam Halabi and Lawrence O Gostin, this “transactional alternative” assumes that the US could strike comparable agreements with nearly every country in the world – “which of course it cannot,” they wrote in a commentary published in the Washington Post.

The WHO is expected to discuss how to address the US withdrawal at its upcoming Executive Board meetings on 2 February and again at the annual World Health Assembly in May. The organization also maintains that the US owes $260.6 million in unpaid membership dues.

WHO says withdrawal makes US and world ‘less safe’

WHO Director General Dr Tedros Adhanom Ghebreyesus at a press briefing in Geneva. Tedros defended the Organization’s COVID-19 response.

The WHO responded to the US’s accusations on Saturday, saying that “[w]hile no organization or government got everything right, WHO stands by its response to this unprecedented global health crisis. Throughout the pandemic, WHO acted quickly, shared all information it had rapidly and transparently with the world, and advised Member States on the basis of the best available evidence.”

WHO Director General Dr Tedros Adhanom Ghebreyesus echoed the sentiment, saying: “While WHO recommended the use of masks, physical distancing and vaccines, WHO did not recommend governments to mandate the use of masks or vaccines and never recommended lockdowns. 

“WHO supported sovereign governments with technical advice and guidance that was developed on the basis of evolving evidence on COVID-19 for them to make policy decisions in the best interests of their citizens. Each government made their own decisions, based on their needs and circumstances.”

The WHO pointed to the US’s global participation in some of the world’s greatest public health achievements, despite the fact that the US promises to continue “leading the world in public health” without collaborating with the UN organization. 

“As a founding member of the World Health Organization, the United States of America has contributed significantly to many of WHO’s greatest achievements, including the eradication of smallpox, and progress against many other public health threats including polio, HIV, Ebola, influenza, tuberculosis, malaria, neglected tropical diseases, antimicrobial resistance, food safety and more.

“WHO therefore regrets the United States’ notification of withdrawal from WHO – a decision that makes both the United States and the world less safe.”

This story is a continuation of Health Policy Watch’s coverage of the US-WHO withdrawal. See related stories here:

Stars and Stripes No Longer Flying at WHO – But US Can’t Really Leave Until Dues are Paid, Agency Says

America First is Not America Absent

 

Image Credits: Arkansas Advocate , E. Fletcher/Health Policy Watch.

Healthcare workers
The mission to ensure safe, effective and affordable diagnostics, therapeutics and vaccines (DTVs) within 100 days of a pandemic threat being identified is not possible in many regions, according to the International Pandemic Preparedness Secretariat.

Global pandemic preparedness is becoming “increasingly fragile at a time of growing biosecurity and geopolitical risk”, according to the International Pandemic Preparedness Secretariat (IPPS), which launched its Fifth Implementation Report of the 100 Days Mission on Tuesday.

IPPS is an independent entity that promotes the “100 Days Mission”, the global ambition to develop safe, effective and affordable diagnostics, therapeutics and vaccines (DTVs) within 100 days of a pandemic threat being identified. 

But pressure on global R&D pipelines, declining investment in pandemic countermeasures, and heavy reliance on a small number of funders mean that the 100-day target is not possible in many areas, according to the report.

“Major reductions in global health and research budgets in 2025 have exposed structural vulnerabilities, disrupted development pipelines, and weakened preparedness,” the IPPS notes in a media release.

“Investment in pandemic countermeasure R&D continued to decline through 2024, with the steepest impacts seen in therapeutics. Pipelines across diagnostics, therapeutics and vaccines remain uneven and clustered in early stages, with limited progression into mid-stage and late-stage development. 

“Progress on enabling systems, including regulatory preparedness, clinical trial readiness, data-sharing frameworks and manufacturing coordination, remains slow,” the media release notes.

Outbreaks of mpox,  a continental health emergency in Africa until last week; the zoonotic spillover risk of H5N1; and outbreaks of Ebola, Marburg, Rift Valley Fever and Chikungunya “have highlighted persistent challenges in early detection, coordination and equitable access to countermeasures”, according to the IPPS, which is funded by the Wellcome Trust and Gates Foundation

“The science needed to respond faster to pandemics continues to advance, but this report makes clear that progress in applying these advances to delivering effective tools is insufficient,” said Dr Mona Nemer, chair of the IPPS Steering Group and Chief Science Adviser of Canada.

“Today, despite the landmark WHO Pandemic Agreement, the world remains vulnerable to funding shocks, uncoordinated R&D efforts and fragile development pipelines – particularly for therapeutics.”

Priorities for 2026

For the first time, the 100-day scorecard includes an assessment of pandemic preparedness and response (PPR) capacity in Africa. 

This evaluates the continent’s capabilities in clinical trials, laboratory systems, regulatory frameworks and manufacturing.

“Advances in platform technologies, including mRNA, monoclonal antibodies and artificial intelligence, continue to offer opportunities to accelerate development,” according to the report, which also identifies “significant pressures”.

However, it notes that Africa shows “growing regulatory maturity and manufacturing capability”. It highlights Rwanda’s integration of the 100 Days Mission framework and scorecard into national preparedness planning as an example of how the mission can be operationalised at the country level.

The report, launched in Paris, identifies 2026 as a decisive year as France begins its G7 presidency.

It  identifies four priority action areas for 2026:

  • Operationalising the Therapeutics Development Coalition to address persistent gaps in antiviral R&D.
  • Enhancing coordination across the diagnostics ecosystem and implementing recommendations from the Global Diagnostics Gap Assessment.
  • Sustaining vaccine investment and strengthening alignment across diagnostics, therapeutics and vaccines.
  • Agreeing on a sustainable mechanism for pandemic preparedness monitoring, including a long-term path for the 100 Days Mission Scorecard beyond the IPPS mandate(which ends in 2027).

 

 

Image Credits: PREZODE , Photo by Carlos Magno on Unsplash.

WHO member states at an Intergovernmental Working Group meeting, negotiating a pathogen access and benefit-sharing (PABS) system.

Only 12 more negotiating days remain until WHO member states hit the May 2026 deadline for an agreement on a Pathogen Access and Benefit Sharing (PABS) system, as part of the new Pandemic Agreement adopted at last year’s World Health Assembly (WHA). 

The gap between developed and developing blocs of countries remains large, and progress has been slow in bridging the divide. A bloc of approximately 100 low-and middle-income countries (LMICs) continues to call for mandatory benefit sharing, including guaranteed LMIC access to vaccines, therapeutics, and diagnostics (VTDs) as the price of their rapid sharing of information on novel pathogens that might pose a pandemic risk.  

High-income countries, on the other hand, remain focused on protecting the pharma innovation ecosystem and ensuring open pharma access to pathogen sequence data. In terms of benefit-sharing, they tend to favor more flexible and voluntary commitments by manufacturers and research institutions to share products and manufacturing know-how with LMICs. 

While some elements of the PABS might actually be settled in time for adoption at  this year’s 79th WHA (18-23 May), other issues are likely to be kicked further down the road, potentially to a future Pandemic Agreement Conference of Parties (COP).  

In the seventh issue of the Governing Pandemics Snapshot, Daniela Morich dissects the choices facing member states.

Longstanding tension between rapid pathogen sharing and access to benefits

Cheers among the lead negotiators as the World Health Assembly adopts the Pandemic Agreement, 20 May 2025

On 20 May 2025, the global health community welcomed the adoption of the Pandemic Agreement (PA) as a much-needed triumph of multilateralism in a year marked by significant challenges and strains on global cooperation.

Although adopted, the Agreement will not be opened for signature until a supplementary Annex on the Pathogen Access and Benefit Sharing (PABS) system is completed—an uncommon feature in international law that temporarily halts the Agreement’s progress toward entry into force until the details of the Annex are agreed.

At the core of the Annex lies a longstanding tension: how to ensure rapid and reliable sharing of pathogens and their genetic sequence data – crucial for managing health emergencies and for the development of health products – while also guaranteeing fair and meaningful access to the benefits derived from their use, such as vaccines and therapeutics.  

Article 12 of the PA sets out the foundational principles of the PABS system. But the specifics – such as the recognition of obligations for countries and manufacturers, benefit-sharing arrangements, and implementation mechanisms – remain to be negotiated. An ad hoc Intergovernmental Working Group (IGWG), open to all WHO member states, has been tasked with translating these principles into operational rules.

Wide divide from the start

Ethiopia representing the position of the Africa group during pandemic agreement negotiations in March 2024.

The IGWG officially began its work in mid-2025. In August, WHO Member States submitted 17 textual proposals reflecting the views of approximately 100 countries. These proposals revealed, from the outset, deep divergences in how countries imagine the PABS System, and those differences have continued to shape the negotiations ever since.  

Developing countries advocate for strong equity provisions, including mandatory benefit-sharing and guaranteed access to vaccines, therapeutics, and diagnostics (VTDs). Their approach relies on transparency and traceability, with a strong role for WHO in administering the system and oversight by a future Conference of the Parties (COP).

Developing country blocs also have placed a greater emphasis  on technology transfer, and as part of that, licensing of medicines and vaccines as core benefits they should reap from the PABS agreement. As such, their proposals prioritize binding obligations operationalized through contractual mechanisms to ensure traceability and enforceability of commitments and to support the development of regional production capacity.

Consistent with this approach, the leading LMIC negotiating blocs, known as the Africa Group and the Group for Equity, as well as Egypt, Libya, Somalia and Sudan jointly submitted an ad hoc proposal for draft contractual agreements for negotiation (see Adam Strobeyko’s piece Avoiding Contract Fatalism.).

High-income countries, by contrast, focus on protecting the innovation ecosystem, maintaining open access to pathogen sequence data, and preserving incentives for private-sector research and development, which is still mainly happening in the Global North.

With regards to benefit-sharing obligations, they tend to favor voluntary and flexible commitments for manufacturers and research institutions. Their concern is that overly rigid obligations could undermine scientific collaboration or discourage investment in pandemic-related technologies.

First draft text does not bridge divides

IGWG3 gets underway on 4 November 2025.

In October 2025, the IGWG’s Bureau, a six-person panel steering the negotiations, released the first Draft Text of the Annex ahead of the Group’s third meeting. Although the text drew significant criticism from many delegations, it nonetheless became the basis for negotiations during the two subsequent meetings in November and December.

Progress was extraordinarily slow. Delegations used the sessions not to narrow differences but to reinsert the language they considered had been omitted from the Bureau’s proposal. As a result, the document expanded from seven pages to 37, producing a dense and unwieldy “rolling text” in which every proposal reappeared.

The only areas where common ground emerged were a few preliminary words on governance elements, notably that the COP would oversee the PABS System and that a PABS Advisory Group would be created.

Following calls for more transparency in the proceedings, the second IGWG meeting marked a surprising shift by deciding, on a pilot basis, to invite stakeholders to observe discussions starting at IGWG3 in November 2025. 

However, this openness was quickly revoked at the beginning of IGWG3, with no access to the negotiating room granted to observers. Further constraints on meaningful participation were introduced in January 2026, when participation was limited to virtual attendance. It is hoped that greater transparency will be allowed as the process moves forward.

Revising the Draft: Gains Limited to Pathogen Definition

The fourth session of the IGWG made some progress in clarifying the definition of a pathogen with pandemic potential. Here, a microscopic view of  SARS-COV-2. 

In the fourth resumed session of the IGWG (20–22 January 2026), progress remained slow. The Bureau, following regular intersessional informal meetings, released a revised draft text.

Some advancement was seen in clarifying language on the definition of “pathogen with pandemic potential,” an important step in defining the system’s scope, but little progress was made elsewhere in the text. Despite a generally positive mood in the room, the ticking clock reinforced a sense of urgency. Progress in bridging the divides continues to be painfully slow.

A small but highly engaged group of relevant stakeholders continues to follow the process closely, although it remains state-led and conducted behind closed doors. Interaction with delegates is limited to short briefings led by the Bureau and is restricted to stakeholders duly accredited to the process.

Are we nearing the finish line?

With the May 2026 deadline approaching – and only 12 actual negotiation days remaining – clear divergences between blocs of countries remain a significant obstacle. 

Additionally, while some issues—such as laboratory networks, databases, and traceability—have been discussed, other critical topics, including financing, have yet to be meaningfully addressed, as highlighted by Suerie Moon in her companion article “Could money grease the wheels of compromise on PABS?”

Against the ticking clock, an overarching  question now looms: which elements of the PABS  parties might be willing to settle now –  and which they might further kick down the road to a future Pandemic Agreement’s COP.

Problematically, these negotiations also unfold against the backdrop of a spate of US  bilateral agreements with  developing countries – so far 15 in all. In these arrangements, seen as a cornerstone of the new US global health policy, aid and commercial deals are offered in exchange for access to pathogen samples and data about disease outbreaks. 

Some experts worry that these deals will negatively affect the negotiations in Geneva, and the future PABS systems, as they could create structural dependency that constrains a country’s ability to share data independently with regional or WHO-coordinated networks.

With only a few months remaining, parties will need to be realistic about what can be achieved. Successfully concluding this work would consolidate years of effort and strengthen the foundations of a more equitable global pandemic preparedness and response system.

Daniela Morich is head of policy engagement and Global Health Platform at the Geneva Graduate Institute’s Global Health Centre.

Explore the three other articles available in the seventh issue of the Governing Pandemics Snapshot:

In  “Avoiding Contractual Fatalism: Lessons from PIP Framework for Standardising PABS contracts” Adam Strobeyko looks at how the experience of the Pandemic Influence Preparedness (PIP) Framework could help inform the PABS process. He examines WHO contracts that enable pharma access to a global network of influenza samples in exchange for benefit-sharing commitments channelled through WHO.

In PABS laboratory networks: building a new system or using what we have? Gian Luca Burci examines whether existing WHO-managed networks, such as the Global Influenza Surveillance and Response System (GISRS), could take on the additional role of a PABS laboratory network, presuming an agreement is reached.

Finally, in her piece, Could money grease the wheels of compromise on PABS? Suerie Moon explores how finance for Access and Benefit Sharing (ABS) could be generated in “interpandemic” times when the absence of a clear pandemic threat provides limited incentive to pharma companies to invest in related products. 

Image Credits: NIAID-RML .

Women are being taught how to access information about contraception on their smartphones in Indonesia. The UN’s Universal Periodic Review (UPR) provides an avenue for human rights activists to advocate for more rights for citizens.

Grassroots organising, using the United Nations’ Universal Periodic Review (UPR) and creating new multilateral coordination are some of the ways to counter the current attack on sexual and reproductive health (SRH), according to activists.

There is a “rise of unapologetic, unabashed, hegemonic masculinity and really harmful gender stereotypes,” Paola Salwan Daher, Women Deliver’s senior director for collective action, told a webinar on the anti-rights pushback.

Far-right governments “are bringing the message that women should not have the same rights as men,” and tech billionaires “have put their incommensurable wealth behind this”, she added.

“We are seeing deeply biased misinformation around women’s bodies, around women’s health, and the undermining of women and girls’ agency.”

To counter what she describes as “Conservative International”, Women Deliver is convening a global gender equality conference in April to enable like-minded organisations “to meet each other to strategise together”. 

“We are organising to push forward a more progressive agenda that really centres the autonomy, the rights to dignity for women and girls,” she said.

Salwan Daher added that the current “crisis of multilateralism doesn’t come from nowhere”.

“It has been exacerbated by the postures of the Trump administration, but really, it was brewing before. It was brewing because of double standards in the application of international law. The genocide in Palestine has really exposed the fault lines,” said Salwan Daher.

“We do not want a world without multilateralism. So now is the time to reimagine collectively what multilateral can look like. How do we make it people-centred? How do we make accountability at the root of everything, every process and every global space? How do we ensure the legal obligations of states?”

Abortion taboo

Pauline Fernandez, coordinator of the Philippines Safe Abortion Advocacy Network (PINSAN), said that despite her country having one of the harshest laws against abortion, there was growing recognition of the need to decriminalise abortion.

“Despite it being criminalised, abortion remains a widespread and urgent reality in the Philippines,” said Frenandez.

“Data shows that upwards of a million women undergo abortions annually, and because of abortion-related complications, up to three women die every day in the Philippines.”

Sustained organising about the importance of decriminalisation had seen PINSAN to her grow from 10 to 130 organisations.

Over 30,000 people have signed PINSAN’s petitionin support of decriminalisation, helped by a recent Netflix documentary on the subject by a famous local filmmaker.

Regular reviews

Dr Virginia Kamowa, regional and country manager at the Global Center for Health Diplomacy and Inclusion (CeHDI), which co-hosted the event, said that the Universal Periodic Review UPR) provides a lever to ensure better SRH services.

“The UPR is the only mechanism of UN that reviews every country on a regular cycle against the human rights obligations of the governments, and produces a public on-the-record government commitment,” explained Kamowa.

“More and more recommendations have been on health,” she said, adding that aroung 82% of health recommendations were accepted by the country being reviewed.

Improving maternal health involved many aspects of SRH, she noted.

Rwanda was reviewed last week, while the reviews of St Lucia, Namibia, Mozambique, Somalia, Seychelles, Sierra Leone and Eswatini are imminent.

“All 193 UN member states undergo a UPR. There’s a national report that is written by the government within the country, but also the UN bodies within the country that also do their own population and stakeholder research, civil society, NGOs and human rights institutions also compile their summary reports.

“During the process, other states ask questions and make recommendations to the country that is being reviewed, and the reviewed country can accept or not those recommendations, and then there is follow up in the next cycle of the UPR review.”

Image Credits: ©Gates Foundation/ Prashant Panjiar.

Stars and stripes lowered at WHO headquarters.

One year after the United States announced its withdrawal from the World Health Organization, a former WHO Headquarters Staff Association President reflects on how presence, governance, and leadership shape influence in global health.

In January 2024, I stood before the WHO’s Executive Board, chaired by Qatar’s Minister of Health, Dr. Hanan Mohammed Al Kuwari. I was speaking as an elected staff member representing more than 10,000 staff across the WHO and its partner agencies. When I opened my remarks by honoring a colleague killed in Gaza, the room, filled with health delegates from 194 member states, fell silent. Across political lines, delegates expressed empathy.

That moment reminded me that global health cooperation does not run on treaties or budgets alone. It is held together by trust, the fragile belief that even adversaries can remain in the same room long enough to cooperate on what keeps people alive.

I did not set out to work in global health. I began my career at a New York investment bank. During the pandemic, I helped lead launch preparations for a COVID-19 therapeutic and saw American leadership at its best through Operation Warp Speed.

I joined the WHO to work on vaccine supply equity so that, in the next pandemic, access and supply chains don’t break along geopolitical lines.  I eventually reported to a senior Chinese official who had risen through the ranks at headquarters. We were supposed to be adversaries. My Taiwanese heritage and American upbringing placed me in a rivalry I did not choose. Yet she treated me with professionalism and fairness. Over time, we built trust and found common ground on expanding access to essential medicines.  But trust is only half the equation. The other half is presence.

America pays, others decide

WHO Director General Dr Tedros Adhanom Ghebreyesus and his senior leadership meet with the WHO Headquarters Staff Association in Geneva in March 2024.

The United States has historically been the WHO’s largest funder contributing roughly 18% to the annual budget through a combination of assessed fees and voluntary donations. Yet Americans are chronically underrepresented in the professional workforce. 

According to the latest workforce data to be presented at the 158th session of the Executive Board in early February, U.S. citizens continue to hold roughly 7% of professional positions.  The European region holds about one in three professional posts, more than four times America’s representation. This influence gap runs to the top. No American has ever served as Director-General. For years, Washington has tried to influence the organization from outside through press releases and funding threats. In these institutions, indignation is noise. Seats are power.

I learned this first hand when headquarters staff elected me President of the Staff Association of WHO’s headquarters, representing about 3000 staff in Geneva as well as HQ-managed offices in Japan, New York City, Budapest, Lyon, Berlin and Tunis. It was a role that put me regularly in the room with Director-General Tedros Adhanom Ghebreyesus and senior leadership. Institutions like the WHO rarely change because they are denounced from afar. They change because people stay in the process long enough to turn criticism into votes, rules and resolutions.

Downsizing Is Not Accountability

WHO
WHO Director General Dr Tedros Adhanom Ghebreyesus meets with staff association presidents for WHO’s African, European and South-East Asian regions and Headquarters (Liu), in Lyon in December 2024.

None of this requires romanticizing the WHO.

It is a glacial bureaucracy. Last year, leadership launched one of the largest downsizings in its history, announcing plans to cut roughly a quarter of the workforce by June 2026, in a massive restructuring exercise. But making an institution smaller is not the same as making it accountable. Thousands of front-line staff were terminated while a shadow workforce of consultants remained. This narrowed a roughly $1.7 billion funding gap without changing how power is exercised or decisions are made and enforced.

The finality of the US decision, and its inevitable budget impacts, began to permeate in December 2024, shortly after the US Presidential elections.

On 17 December WHO leadership gathered in Lyon, France, with President Emmanuel Macron for the opening of the new WHO Academy. The setting was elegant. It felt like a toast raised on the proverbial cruise ship deck while someone, somewhere, had already spotted  the iceberg. Yet the music played on.

In the afternoon session, the mood shifted.  Dr. Tedros paused and said quietly, “Let’s give them a peaceful holiday.” Shortly afterward, WHO staff were told they would receive two additional days of leave. It was a kind gesture, and also a telling one. The calm before the storm. By then, those of us who had been in Lyon knew the die was already cast – the US would withdraw on Day 1 or Day 2 of President-elect Donald Trump’s second term in the White House.  On Inauguration day, 20 January 2025, the announcement was made.

Navigating the Rupture: Beijing’s Opportunity in America’s Absence

China speaks at the February 2025 WHO Executive Board meeting. The US largely abstained from participating following January’s announcement of its withdrawal.

The United States withdraws largely alone. Except for Argentina,  every other WHO member state has chosen to remain. And in fact, for historical reasons there is no real legal provision allowing WHO member states to withdraw, with the exception of the United States. 

With the next Director-General election approaching in 2027, leadership choices and reform priorities are being shaped by those still present. The question is whether American absence makes China’s influence easier, or harder, to counter.

We have seen this before. In 2019, China ran a disciplined campaign to win the top job at the United Nations Food and Agriculture Organization (FAO). U.S. officials were caught off guard. “It made us look like complete fools,” one State Department official was later quoted as saying. This is not about relitigating 2019. It is about not repeating the same mistake.

In May 2025, Beijing arrived at the World Health Assembly with about 180 officials, according to press and delegate accounts, and announced a $500 million pledge to the organization. Washington sent no delegation. Taiwan was again blocked by WHA member states from being granted observer status, this time without visible resistance.

Winning the 2027 Director-General election is an even bigger strategic prize. The organization that sets global health standards and coordinates pandemic response is an asset Beijing will pursue with patience. The groundwork is being laid now, while the United States steps away.

Reform Requires Presence

Countries indicating their wish to speak about the pandemic agreement in Committee A, just prior to a vote approving the agreeement.

So who wins when America leaves? It is a Catch-22.

US Secretary of State Marco Rubio and Secretary of Health and Human Services Robert F Kennedy Jr have been clear that the United States should no longer write blank checks to international bureaucracies that lack accountability. 

As Rubio recently put it, “sometimes true leadership means knowing when to walk away.” Demanding results is not retreat. It is a leadership responsibility, some critics of continued engagement might say.

They raise a fair point. Staying only works if reform and cooperation are possible. 

But in global health, they are – if and only if U.S. leadership is present. Allies do not follow a country that leaves the room. They follow one that shows up with a plan. The world is not waiting for us. It is waiting for someone to lead.

What Re-engagement Would Require

WHO’s 78th World Health Assembly meets at Geneva’s Palais des Nations 19-27 May, 2025.

If Washington really wants a more effective and accountable WHO, the pathway to getting that is clear and concrete.

Reengage with conditions tied to transparency and governance. Align representation with contribution by rebuilding the American professional pipeline. Place American experts where technical norms and standards are written.

Demand enforceable oversight, not cosmetic restructuring. Work with our allies on the Executive Board to advance a serious reform agenda. Reinvigorate WHO’s technical expertise as a truly merit-based organization that recruits and hires the most qualified staff at all levels transparently and internationally – and not through fixed appointments, political favoritism, or over-reliance on consultants who just happen to be living in relatively close proximity to Geneva. Deliver a genuine reset, not just headlines.

Make WHO great again.

The Way Forward: Leadership is a Choice

World Health Assembly member state delegates pose with WHO Director General Tedros after a critical HA Committee vote adopting the Pandemic Agreeemnt on 20 May 2025.


Today, the American flag no longer flies at WHO headquarters. That absence is visible to every delegation, every staff member, and every government navigating the institution that remains.

The Pandemic Agreement is moving forward, and the campaign to elect a new WHO Director-General in 2027, when Tedros’ second term ends, is already underway. WHO will evolve with or without the United States. Even Dr. Tedros has described U.S. withdrawal as a “lose-lose.” On that point, he is right.

America First cannot mean America absent. While our stars and stripes have come down, the threats to our health, security, and sovereignty have only gone up. I remain hopeful that one day our flag can fly again over an institution worthy of American taxpayers’ support and the American people’s trust. Leadership has always been a choice, and we the American people can make it again: to lead as one Nation, indivisible, with peace, strength, and the accountability our citizens deserve.

Christina Liu

Christina Liu served at WHO from 2022 to 2025 as a technical officer on vaccines and access to medicines. She was the President of WHO Headquarters Staff Association from 2024-2025.

A US citizen and native of California, she is currently a Board Advisor for Global Public Health at BioLiterate.  She has over 18 years of experience spanning global health, international policy and in the pharmaceutical industry, including with Roche and Novartis. Liu holds a dual Masters in Biotechnology/MBA from The Wharton School and the University of Pennsylvania.  

Image Credits: Anonymous/HPW, Christina Liu, WHO, WHO/Pierre Albo .

The Missing Star-Spangled Banner: A vacant flagpole stands between the flags of Uruguay and Uganda at the WHO headquarters in Geneva after the United States said it had completed its withdrawal from the World Health Organization.

The United States said Thursday that it had officially completed its withdrawal from the World Health Organization (WHO). 

But WHO member states are not obliged to accept the US departure as legally binding until it pays up on some $260.6 million in dues owed for 2024- and 2025, WHO’s Director General contends in a report to WHO member states, published this week. 

The report, to be discussed at an upcoming meeting of WHO’s Executive Board governing body 2-7 February, cites a little-known provision of the original Congressional Act ratifying US membership in WHO in 1948, which states:

“The United States reserves its right to withdraw from the organization on a one-year notice, provided, however, that the financial obligations of the United States to the organization shall be met in full for the organization’s current fiscal year.”

Meanwhile, an angry joint statement by US Health and Human Services Secretary Robert F. Kennedy Jr and US Secretary of State Marco Rubio accused WHO of holding hostage the US flag that has now been removed from its pole outside of WHO’s Geneva headquarters until the dues are delivered.

“Even on our way out of the organization, the WHO tarnished and trashed everything that America has done for it.  The WHO refuses to hand over the American flag that hung in front of it, arguing it has not approved our withdrawal and, in fact, claims that we owe it compensation. From our days as its primary founder, primary financial backer, and primary champion until now, our final day, the insults to America continue.”

Thursday’s US announcement – and ensuing brouhaha over the legalities around withdrawal – comes exactly one year after President Donald Trump signed an executive order to leave the agency, within hours of being inaugurated as President in January 2020.  

Blames WHO for delayed action on global emergency and transmission modes of virus 

Too late? WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee on 30 January 2020, when the COVID International Health Emergency was first declared.

A separate statement by the Department of Health and Human Services (HHS), announcing the completion of the year-long withdrawal period on Thursday, focused on WHO’s behaviour during the COVID pandemic, charging that late response to the fast-moving virus in the early days of the pandemic had exacerbated the damage done. 

“The WHO delayed declaring a global public health emergency and a pandemic during the early stages of COVID-19, costing the world critical weeks as the virus spread,” charged HHS in its statement. 

“During that period, WHO leadership echoed and praised China’s response despite evidence of early under-reporting, suppression of information and delays in confirming human-to-human transmission. The organization also downplayed asymptomatic transmission risks and failed to promptly acknowledge airborne spread,” said the HHS statement.

“After the pandemic, the WHO did not adopt meaningful reforms to address political influence, governance weaknesses or poor coordination, reinforcing concerns that politics took priority over rapid, independent public health action and eroding global trust. 

“Its report evaluating the possible origins of COVID-19 rejected the possibility that scientists created the virus, even though China refused to provide genetic sequences from individuals infected early in the pandemic and information on the Wuhan laboratories’ activities and biosafety conditions.”

In a response issued Saturday, WHO said:  “While no organization or government got everything right, WHO stands by its response to this unprecedented global health crisis. Throughout the pandemic, WHO acted quickly, shared all information it had rapidly and transparently with the world, and advised Member States on the basis of the best available evidence. WHO recommended the use of masks, vaccines and physical distancing, but at no stage recommended mask mandates, vaccine mandates or lockdowns. We supported sovereign governments to make decisions they believed were in the best interests of their people, but the decisions were theirs.”

Spat over US payment of back WHO dues and WHO’s return of US flag 

Lowering the stars and stripes from WHO headquarters under a grey Geneva sky Thursday.

Along with the flag spat, the joint press release by Kennedy Jr and Rubio, took a deeply bitter tone saying:  

“The WHO tarnished and trashed everything that America has done for it…..Although the United States was a founding member and the WHO’s largest financial contributor, the organization pursued a politicized, bureaucratic agenda driven by nations hostile to American interests.” 

Their statement also stressed that “all U.S. funding for, and staffing of, WHO initiatives has ceased.” However, behind the scenes, some White House sources as well as global health experts questioned if this is entirely the case. For instance, US Centers for Disease Control scientists participated in last year’s WHO consultation to determine the composition of the seasonal flu vaccine; a senior HHS official told reporters in Washington that such limited engagement might still continue in this year’s session, planned for February.

In terms of funding, new US global health policy will focus on “direct, bilateral, and results-driven partnerships.” Since withdrawing from WHO and abruptly closing down USAID, Washington has signed some 15 such bilateral deals mostly with African countries, amounting to an estimated $16 billion. See related story.

One Year Later: The Effect of US ‘Chainsaw’ on Global Health

WHO – legally, US needs to pay dues to withdraw  

The unpaid dues at the center of debate include assessed contributions of $130.3 million for 2024, which the previous US Administration of former President Joe Biden failed to pay before Trump took over the White House in January 2025. Added to that is another $130.3 million in unpaid dues  for 2025, before withdrawal took effect this January. 

In a report to the upcoming EB meeting, WHO Director General Dr Tedros Adhanom Ghebreysus, notes that in fact, there is no legal means for a country to withdraw from the Organization – short of a change in WHO’s 1948 Constitution that another member state might find “unacceptable”. Since WHO has never changed its Constitution that remains purely theoretical. 

“[t]he draftsmen of the Constitution of WHO, by reason of the world-wide character of  the struggles against disease, placed great emphasis on the need for the organization to be completely universal, and, as in the case of the Charter [of the United Nations], deliberately omitted any withdrawal clause,” states the WHO report. 

Uniquely, however, among all 194 WHO member states, the US Congress retained the legal right to withdraw when it ratified the US decision to join WHO on 14 June 1948 – a condition accepted by WHO.   

The Congressional act, however, also committed the US to pay up on outstanding dues before it leaves: 

“In adopting this joint resolution the Congress does so with the understanding that, in the absence of any provision in the World Health Organization Constitution for withdrawal from the organization, the United States reserves its right to withdraw from the organization on a one-year notice, provided, however, that the financial obligations of the United States to the organization shall be met in full for the organization’s current fiscal year.”   See related story:

Member States to Discuss US Withdrawal from WHO as Failure to Pay 2024-25 Fees Violates Legal Obligations

Argentina’s withdrawal not legally valid 

WHO Executive Board in session on Wednesday 5 February 2025, just as Argentina’s decision to withdraw was announced.

The lack of any real legal offramp for other nations to leave WHO also means that Argentina’s February 2025 declaration that it was withdrawing is legally invalid, and need not be accepted by WHO member states, according to the Director General’s EB report: 

“Unless the Health Assembly were to decide to adopt a different approach to this issue than it has taken on previous occasions, the conclusion may be drawn that the purported notification of withdrawal by Argentina should not be accepted as effective.”

The notices of withdrawal by Argentina and the United States are not the first by disgruntled member states.  

In 1949-50, at the height of the cold war, the Soviet Union and six Soviet puppet governments in Ukraine, Belorussia, Bulgaria, Romania, Albania and Czechoslovakia – all notified WHO that they were withdrawing. By 1956, the member states had all rejoined, with WHO’s agreement to accept a symbolic fee for the time that their membership was suspended.   

In response to a query by Health Policy Watch, a WHO spokesperson said that the legal issues around the US and Argentinian moves would be further discussed by WHO member states at the upcoming WHO Executive Board Meeting, February 2-7 – with the final decision of how to respond left up to them. 

‘Lose-lose’ proposition

WHO
WHO Director General Dr Tedros Adhanom Ghebreyesus calls on the US to return to WHO in May 2025 – one of a series of appeals over the past year.

Over the course of the past year, Director General Tedros has launched various appeals both public and behind the scenes to the US to reconsider its action – saying that the withdrawal is a lose-lose proposition. 

Loss of support from the US, historically WHO’s largest donor, has meanwhile triggered a budget crisis, leading to the planned reduction of about 25% of the regular workforce by June 2026 – and turmoil amongst staff. 

Even with the drastic cutbacks, the agency still has to fill an outstanding $1 billion budget deficit for the current 2026-2027 biennium of planned spending.  See related story here:

EXCLUSIVE: WHO Cutting Up to 25% of Staff by June 2026 – But ‘Shadow Workforce of Consultants’ Is Unreported  

How to woo back the US?

HHS Secretary Robert F Kennedy Jr has fiercely criticized WHO and declared that the US would build an alternative global health infrastructure.

Critics of Washington’s moves both in the US and internationally have called upon the Trump administration to reconsider – saying that withdrawal will only exacerbate the very problems that it has claimed the Organization is fostering.   

Former CDC director Tom Frieden, described the move as a “grave error”: “Walking away from WHO doesn’t create accountability or reform. It gives the U.S. less say and less warning. History shows what cooperation can achieve. Through WHO, the world eradicated smallpox and reduced millions of preventable deaths. Those successes protected Americans too,” Frieden said.

“Because these emergencies can start anywhere, a multilateral approach involving all countries is needed. Global health security is squarely in the U.S. national interest,” said the Canadian physician General Peter Singer, a former senior advisor to Tedros, in Think Global Health, published by the Council on Foreign Relations. 

But Singer also called on WHO and its member states to advance a deeper reform agenda – shaped around the three pillars of “accountability”, “innovation” and “trust” – noting that the looming 2027 election of a new WHO Director General offers a pivotal opportunity for deeper institutional change.  

“WHO’s decisions on the origins of the pandemic, mode of transmission, and its recommendations on public health measures and quarantine—even when defensible on scientific grounds—contributed to controversy and appear to have affected trust among governments and public alike,” argued Singer. 

“In public health crises, institutions should actively seek to challenge their own internal decision-making,” he added, calling for more proactive debate considering adversarial points of view (red-teaming) during internal decision-making as well as better monitoring of public attitudes.  

“The election of a new director general in May 2027 offers an opportunity to revisit these issues,” Singer added, saying, “The ideal candidate would be one who underscores country ownership, revitalizes the WHO’s results agenda, promotes the organization as the world’s leading scaler of health innovations, makes the WHO the most neutral organization in the UN system, and establishes mechanisms to protect trust in pandemics.” 

See related story here:

America First is Not America Absent

–Updated 25.1.2025 with the WHO response to the US press statements.

Image Credits: Felix Sassmannshausen/HPW, Twitter: @WHO, Anonymous/HPW, Health Policy Watch , HHS.

Guinea-Bissau Health Minister Quinhim Nanthote (right), with his director-general, Dr Armando Sifna.

A controversial trial to examine various impacts of the hepatitis B vaccine on newborn babies in Guinea-Bissau has been “suspended or cancelled”, the country’s Health Minister, Quinhim Nanthote, told a media briefing convened by the Africa Centres for Disease Control and Prevention (Africa CDC) on Thursday.

This is despite recent assertions by the US Health and Human Services (HHS) Department, which is funding the trial, that it was going ahead.

Nanthote initially told the briefing that his country’s ethics committee had not yet held a meeting about the trial, but later said that it “did not have the required technical resources” to approve the trial.

Nanthote, who addressed the briefing in military fatigues, was only appointed health minister on 29 November 2025, following a military coup three days earlier. He was not part of discussions about the trial, which has been proposed by the  Danish research group, Bandim Health Project.

According to Bandim’s trial protocol, dated 14 January, “the Guinea-Bissau Committee of Ethics approved the trial on 5 November, 2025, with approval number 036-CNES-INASA-2025”. However, this was before the military coup.

Global outrage

There has been global outrage over the ethics of the trial, which would only give half the 14,000 babies it aims to enrol a hepatitis B vaccination shortly after birth – despite clinical evidence that early vaccination is highly effective at preventing mother-to-child transmission of the virus, which is the leading global cause of liver disease.

Although babies in the country only start to get vaccinated against hepatitis B at six weeks,  around 11% of children in the country are already infected with hepatitis B by the age of 18 months,and the government has resolved to introduce vaccination at birth from 2027/8.

While Bandim says it will stop its trial before the national rollout, health experts assert that it is unethical to knowingly withhold a proven treatment from a baby born to a mother with hepatitis B (the trial is single-blinded, so researchers will know which babies get the vaccination and which get the placebo).

US involvement

The US Centers for Disease Control and Prevention (CDC) awarded Bandim a $1,6 million five-year grant to “assess the effects of neonatal Hepatitis B vaccination on early-life mortality, morbidity, and long-term developmental outcomes”, according to the US HHS federal register.

Dr Christine Stabell Benn, co-leader of Bandim, is an adviser to the US Advisory Committee on Immunization Practices (ACIP), which recently resolved to stop recommending hepatitis B vaccines to US newborns. 

HHS Secretary Robert F Kennedy Jr fired most of the ACIP members last year, replacing them with a committee dominated by vaccine critics.

For years, Stabell Benn, co-principal investigator of the Guinea-Bissau trial, has researched the “non-specific effects” (NSE) of vaccines. She and colleagues have conducted trials involving thousands of children in Guinea-Bissau and Denmark, and assert that all vaccines should also be tested for NSEs.

One of the research aims of their Guinea-Bissau trial is to investigate the effect of the vaccination “on neurodevelopment by five years of age”. This dovetails with Kennedy’s belief that the rise of autism is linked to childhood vaccinations.

“RFK Jr. has manipulated the [Guinea-Bissau] study to support his unsupportable, science-resistant beliefs about harms caused by the hepatitis B vaccine,” observed US paediatrician Dr Paul Offit, co-inventor of a rotavirus vaccine, on his Substack platform.

Role of Africa CDC

Africa CDC Director-General Dr Jean Kaseya

Africa CDC Director-General Dr Jean Kaseya said that African countries were in “total control” of clinical trials conducted in their countries.

However, Africa CDC has developed a 13-step guide to assist countries.

“I was talking to the minister [of Guinea-Bissau] who called me three days ago and clearly said, told me: ‘DG, I’m a new Minister. I’m still waiting for the two steps, the National Medicine Regulatory Authority and the National Ethics Committee, to come to brief me and to give me the recommendations. I’m also asking if Africa CDC can come and support us to see this protocol and all other documents, then I can make a decision based on this recommendation’,” Kaseya told the media briefing.

He also dismissed a report that unnamed HHS officials had made disparaging remarks about Africa CDC over its contention at a media briefing last week that the trial had been cancelled.

“We have our diplomatic relationship with the US. Yesterday, senior people from HHS were talking to senior people from Africa CDC, and I was briefed that they don’t know anything about any statement against Africa CDC,” said Kaseya, who said that his organisation has an “excellent relationship” with the US government.

Kaseya added that Africa CDC had decided not to involve itself in the bilateral Memorandums of Understanding that the US was negotiating with African governments under its “America First Global Health Strategy”.

However, he said that the implementation of the MOUs would be discussed at a meeting of health and finance ministers that he is convening on 13 February.

NCD WEF
As the World Economic Forum (WEF) met in Davos this week, a new WEF report on NCDs reflects the influences of powerful groups on disease priorities.

The World Economic Forum’s (WEF) latest report on acting early on noncommunicable diseases (NCDs) signals more than urgency. It signals a shift in what counts.

Beneath familiar calls for earlier action sits a quieter move: a re-ordering of NCD priorities themselves. Some diseases now sit firmly at the centre of the agenda. Others, no less prevalent or consequential, are absent or muted.

The clearest indicator is the report’s treatment of chronic kidney disease (CKD). CKD is presented, not as a downstream complication, but as a core NCD, positioned comfortably alongside cardiovascular disease, diabetes, cancer, and chronic respiratory disease. No extended justification is offered. Its inclusion is just assumed.

CKD’s elevation is overdue, but its inclusion in the WEF report also reveals how NCD categories solidify. Diseases move to the centre not only because of burden, but because they align with existing biomedical pathways, specialist care models, insurance logic, and pharmaceutical governance. 

Seen this way, the report is not simply about acting earlier. It is about which disease problems global health institutions are structurally prepared to organise around.

The politics of NCDs

NCDs have never been a neutral list. They are the product of political and institutional settlement. Inclusion brings visibility, financing, and organisational ownership. Exclusion does not erase a condition, but it shapes how seriously it is taken in policy, planning, and budgets. What this report suggests is that the settlement is shifting again, quietly rather than through open debate.

The contrast between what fits and what does not is striking. Oral health is absent altogether, despite affecting more people globally than all other NCDs combined. Dementia barely registers, even as it reshapes ageing societies and long-term care systems. 

Air pollution appears only as a generic risk factor, detached from its regulatory implications. Obesity and physical inactivity are acknowledged but they never organise the analysis. Mental health is present, but thinly so. Eye health and several other NCDs are missing entirely.

This is not ignorance. The WEF itself has published economic analyses making the case for investing in oral health. It is well aware of dementia, air pollution, and obesity as global challenges. The issue is not whether these conditions matter, it is whether they fit prevailing system architectures.

Institutional compromises

Debates around expanding the NCD frame, including the so-called 6×6 perspective, were never simply about adding conditions to a list. They exposed how the NCD framework hardened into an institutional compromise, privileging problems that are easier to govern, finance, and narrate. 

Oral health and others were excluded not because the evidence was weak, but because their inclusion would have unsettled that compromise.

What the WEF report suggests is that the frame is being adjusted again, but cautiously. Rather than opening outward to accommodate conditions that strain existing arrangements, it tightens inward around those that reinforce them.

 CKD aligns neatly with this logic. It can be framed as an extension of diabetes and hypertension. It lends itself to biomedical markers, specialist pathways, and pharmaceutical management. It fits insurance systems and performance frameworks. 

Crucially, it does not force difficult conversations about food systems, sugar, taxation, or commercial power. It can be absorbed without rewriting the rules.

Other conditions are less accommodating. Oral diseases pull sugar into view as a specific commercial determinant, not a vague lifestyle choice. They expose the fragility of private financing and fee-based care, and make inequality impossible to ignore. Dementia collapses the boundary between health and social care.

 Air pollution pushes responsibility far beyond the health sector. Climate-related exposures, including extreme heat, increasingly shape NCD risk and outcomes, yet remain difficult to absorb into disease-specific prevention frameworks, as they demand action across labour policy, urban design, housing, and climate governance. Obesity, if taken seriously, leads quickly to trade policy and regulation.

These are not marginal complications. They are precisely the kinds of questions that strain consensus and unsettle partnerships.

Inclusive understanding

This quiet consolidation sits alongside longer-standing efforts by groups such as the NCD Alliance to defend a broad and inclusive understanding of NCDs. That advocacy has helped keep multiple conditions visible in political commitments, even as institutional practice increasingly favours a narrower, more governable set of priorities.

The institutional setting matters. The WEF operates through public–private convening. Pharmaceutical companies, diagnostics firms, and health-technology actors are not peripheral to its health work; they are part of the room. This does not mean reports are written to serve corporate interests, but it does shape which narratives travel easily and which stall.

One contemporary signal reinforces this pattern. This week at the WEF in Davos, a global partnership was announced between Colgate-Palmolive (the leading global manufacturer of oral hygiene products) and the WHO Foundation. 

At a moment of tightening budgets at WHO, including the loss of dedicated oral-health staff, such arrangements are widely hoped to help stabilise institutional capacity and preserve visibility for conditions otherwise at risk of further marginalisation.

Analytically, they reflect the same logic at work: when conditions fall outside the core NCD architecture, they advance through parallel channels rather than through the centre of system reform.

The risk is subtle but real. The NCD discourse begins to tilt away from the conditions that most shape lived experience towards those that best fit institutional comfort. Authority shifts not because of burden or equity, but because of governability.

CKD did not move to the centre by chance. It arrived because it belongs to the version of NCDs that the global health sector currently finds easiest to manage. Other conditions remain outside, not because they matter less, but because they ask harder questions about responsibility, power, and what health systems are ultimately for.

That is what this report reveals. It is not primarily a story about acting early. It is a story about how carefully and quietly the boundaries of action are being redrawn.

Habib Benzian is Professor at the University of the Western Cape (Cape Town, South Africa), Noel Martin Visiting Chair at the University of Sydney’s Dental School; and a member of the Lancet Commission on Oral Health. He advises governments and international organisations on health policy and equity.

 

 

Image Credits: WEF.