By Professor Ilona Kickbusch
'People are crazy and times are strange' is a line from Bob Dylan’s song 'Things Have Changed' released in 2000. It applies fully to what the global health community is experiencing now. Clearly the golden age of global health is over. The global health hegemon has become a global health risk. We saw it coming – but we did not really prepare.
After over 30 years of continued growth and relative stability of the system, the present depth of disruption could not be imagined. Not only is the global health hegemon turning his back on the system, but in a multipolar world experiencing a polycrisis, global health and its institutions are no longer a priority – despite the experiences of the pandemic. Trump’s America First foreign policy has exited the concept of “U.S. global health leadership” which was accepted with bipartisan support as “soft power” and “enlightened self-interest” since the early 2000s. This was inspired by the US President’s Emergency Plan for AIDS Relief (PEPFAR) launched by President George W. Bush on January 3, 2003.
The extent to which “US leadership” and support – political, financial and intellectual – kept the global health system running was blatantly obvious, but nobody wanted to talk about it. Until the end of last year it was business as usual in global health, with demands for more Development Assistance for Health (DAH), increased budgets of international health organizations and high expectations for replenishments and investment rounds (IHP, 2025). Probably everyone hoped it would just be the World Health Organization (WHO) that would suffer if another letter were sent to declare the USA exit from the organization (The White House, 2025). Now we see that no more funding is forthcoming for UNAIDS and UNFPA, with probably more to follow.
Clearly the golden age of global health is over. The global health hegemon has become a global health risk. We saw it coming – but we did not really prepare.
One of the most decisive actions that shaped the new arena was the decision by the Bill and Melinda Gates Foundation to call its program to save lives in developing countries “global health” – which dwarfed other concepts of global health. Those that were focused on multilateralism and cross-border cooperation (like pandemic preparedness and response), supporting universal health coverage, agreeing on values and principles, as well as norms and standards and global public goods never found sufficient support. This was also reflected in the lack of funding for the WHO.
Those that were focused on multilateralism and cross-border cooperation (like pandemic preparedness and response), supporting universal health coverage, agreeing on values and principles, as well as norms and standards and global public goods never found sufficient support.
The ever more convoluted global health system that had its beginning in 1989 survived two major crisis – the financial crisis in 2008 and the COVID crisis in 2020-22 – without having to introduce major changes in mindset, governance or financing. Indeed, the powerful rationale of the global health finance architecture and its steady growth might well have lulled governments (and global health initiatives and programs) into expecting that Development Assistance for Health (DAH) will continue to flow. It might be worth remembering that the starting point for global health in 1990 was at USD 8.6 billion, which grew to USD 33.6 billion by 2008, the year of the economic crisis. It was highest during the COVID years of 2021 and 2022 (more than double at USD 84 billion and USD 71.1 billion respectively) and still at USD 64.6 billion in 2023 (IHME, 2024).
The HIV/AIDS response remains a giant in the system. PEPFAR alone contributed 100 billion USD to the system over the years. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) raised 15.7 billion for its 2023-2025 replenishment. Any reduction of these flows will have widespread implications for global development initiatives, forcing NGOs and international partners to adjust their strategies, offices and staff to align with changing priorities. Many organizations and programs – in Geneva and New York, in donor countries and in recipient countries - are threatened, thousands of jobs are lost.One study has analyzed the devastating health and financial potential impact of abruptly stopping PEPFAR (Neilan, A. & Bekker, L-G., 2025).
Even before the action by the US, ODA had started to fall in many countries – especially in view of the costs of the Ukraine war and commitments to new European security objectives. The UK Prime Minister has just recently announced that the UK’s Official Development Assistance (ODA) budget will be cut from 0.5 percent to 0.3 percent of the gross national income (GNI) by 2027 (Gov UK, 2025), in order to fund the defense budget. This has led the development secretary to resign. A significant number European donor governments - Netherlands, Germany, Switzerland, Italy and France are considering considerable cuts in their ODA budgets for 2025. Only a few like Spain and Denmark still aim to increase their contributions.
But now change has hit with unforeseen brutality: The second Trump administration has not just reduced ODA, it has culled the US system of programs, research, institutions and people overnight and has iin consequence destroyed a significant part of the global health infrastructure. For example, it cut 90 percent of foreign contracts funded by the US aid agency (USAID), stopped research at the NIH, weakened the CDC and FDA and sacked thousands of its staff in Washington (The Atlantic, 2025). No one imagined that the backbone of global health would be destroyed with such vehemence and rapidity.
But now change has hit with unforeseen brutality: The second Trump administration has not just reduced ODA, it has culled the US system of programs, research, institutions and people overnight and has iin consequence destroyed a significant part of the global health infrastructure.
The day of Trump's second inauguration, January 20, 2025 signals the beginning of the end of US leadership in global health, with the letter to leave WHO exemplar for more to come. It marks the next big revolution for global health. Many health advocates still try to argue rationally that this is bad politics and will harm the USA because the significant “soft power” of health programs – saving lives, empowering people, supporting democracy and human rights – strengthens Americas position in the world. Indeed, they argue, it would strengthen China, who would race to fill the void. Such an argument only partly holds, since China already has a significant presence, both in multilateral organizations and in many low- and middle-income countries (LMIC). For example, while U.S. foreign investment to Africa has declined steadily since 2010, China has sustained its financial flows to the continent.
It makes no sense to use the old arguments; the concept of “soft power” does not fit the logic of an "America First" transactional diplomacy mind-set that is centered on spheres of influence and would be willing to leave certain parts of the world to China, just as it presently does with Russia. The present global health system is based on a set of universal values that drive priorities, on joint solutions to common challenges and on an approach to health diplomacy that accepts a UN rules-based international order and aims for win-win solutions; health is seen as a common purpose as “no-one is safe until everyone is safe”. The Trump administration in contrast follows the impulse that “might is right.” “President Trump will restore world peace through American strength” (Wilson, E., 2025).
In view of the USAID cuts there are some surprising responses from African heads of State. The President of Ghana sees the cuts as a wakeup call “to take bold steps by investing in local industries, improving infrastructure, and ensuring good governance to attract African investors”. The president of Rwanda states 'I think from being hurt; we might learn some lessons.' Some voices say that finally global health organizations will be moved from expensive Geneva and New York to places in the Global South.
Important African scholars have long considered the present charity-based narrative and system of ODA unfit for purpose – indeed it might have helped undermine the building of sustainable health systems in African countries and reduced the ability to respond adequately to the COVID pandemic.
Dean Acheson wrote his memoirs after his tenure as US Secretary of State (1949-1953) and called them „Present at the creation“(of the liberal world order) (Ricks, T.E.; 2017). We are currently present at its destruction, with significant consequences for global health. The hegemon is gone and has left a financial and political wasteland. Important African scholars have long considered the present charity-based narrative and system of ODA unfit for purpose – indeed it might have helped undermine the building of sustainable health systems in African countries and reduced the ability to respond adequately to the COVID pandemic (Nonvignon, J., et al., 2024).
A new system would build on a power shift, innovative financing and new responsibilities for many of the actors involved. But even this important debate was not prepared for the tectonic geopolitical changes, and for how quickly change would come. But where there is a gap, something will fill it. This should be the opportunity to build something new that is not burdened by the old power structures – a real opportunity for a new group of actors to come forward and shape global health for the future.