The election of Donald J. Trump, with his mistrust of international institutions and his history of proposing deep cuts to foreign aid, has complicated a perilous landscape for global health organizations that were already in a frantic competition for sharply reduced funds.
Organizations that support the cornerstone health programs to vaccinate children, treat people with H.I.V. and stop the next pandemic through disease surveillance, among other goals, are seeking billions of dollars from high-income countries.
Their demands for support reflect mounting health challenges: Rates of infection with dengue fever are exploding in Latin America. The mutated mpox virus is increasingly transmissible between people, and there are fears that H5N1, avian influenza, is also evolving to spread between humans. Deaths from cholera, an ancient scourge, and measles are rising. The parasite that causes malaria is increasingly resistant to the drugs to treat it, and an invasive malarial mosquito is threatening African cities.
The organizations seeking financial commitments and the countries that fund them have helped save millions of lives in developing countries. The global rate of child mortality has dropped by more than half in the two decades since 2000. Malaria infections plummeted as bed nets and better drugs were distributed. H.I.V. went from being the top global killer to, in many places, a well-managed chronic illness.
The reality that these organizations are unlikely to get anywhere near the amount of money they are seeking is driving debate about whether — and how — the current global health system should be restructured.
Global health priorities are now competing with climate change and wars for funding, and aid budgets have already been cut in major donor countries, including Britain, Germany and Japan. Health organizations are bracing for the likelihood that the second Trump administration will sharply reduce contributions from the United States, as well.
Currently, the United States provides about half of all aid for global health, exceeding that of all other donor countries combined.
In his first term, Mr. Trump pulled the United States out of the World Health Organization and sought to slash American donations to the Global Fund to Fight AIDS, Tuberculosis and Malaria and to PEPFAR, a program that supplies much of the H.I.V. treatment to Africa.
The Biden administration restored U.S. commitments to global public health, rejoining the W.H.O. and making major pledges to the Global Fund and other organizations.
The United States is currently the largest donor to Gavi, the organization that supplies vaccines for the developing world. But Robert F. Kennedy Jr., Mr. Trump’s nominee for health secretary, has worked to undermine confidence in vaccines around the world through his nonprofit group, Children’s Health Defense.
The White House does not control the foreign aid budget directly, and Congress did not approve Mr. Trump’s proposed cuts to aid in his first term. But it is not clear that the bipartisan coalition that preserved funding for these institutions still exists. This past year, Congress reauthorized PEPFAR for only one year instead of the usual five.
“Raising funds today is simultaneously more urgent and more challenging, even for an organization that does vital, lifesaving work,” said Anil Soni, executive director of the World Health Organization Foundation, which seeks support for the W.H.O., the United Nations’ health agency, from philanthropists and the private sector.
The W.H.O. has operated with a budget made up of membership fees and extra contributions from countries and a few big philanthropies — particularly the Bill & Melinda Gates Foundation. Hoping for more reliable funds, and a bigger budget for emergency response, the organization is now seeking $7 billion from countries, the private sector and other charities in what it calls an “investment round.”
Gavi is asking donors for $9 billion. The Pandemic Fund, created after the start of the Covid-19 pandemic to prepare for a future global outbreak, is asking for $2 billion. PEPFAR will need reauthorization early in the New Year.
The dryly named International Development Association — an arm of the World Bank, which is the single largest source of funds for developing countries, much of which goes to health spending — is seeking about $30 billion.
And the Global Fund has an outstanding bill, as well. The organization held its last funding round two years ago and received pledges of $15.8 billion, but only $7 billion of that amount has been handed over by donors. (A spokeswoman for the fund says that is on track for the usual pattern of disbursement and that the fund’s leaders have no concerns that they will not receive the full amount.)
Gavi has recently enlisted support from new donors, such as South Korea and Indonesia, but has pledges so far of just $2.5 billion, far short of its $9 billion target.
The W.H.O. is also tapping new sources of funding from philanthropies and countries such as Saudi Arabia but has raised only about $3.8 billion of its $7 billion goal. Currently, the United States is the largest funder, supplying nearly a fifth of the W.H.O.’s core annual budget through membership fees and voluntary contributions; these would end if the United States withdrew from the organization.
Recognizing the fatigue with aid, its proponents — including the Biden administration in its final months — have sought to reframe support for it not as charity but as an investment in mutual security, as infectious diseases respect no national boundaries.
“It really behooves us to try and do both things, to acknowledge that people are tired because public health has taken up a lot of the conversation in recent years — and yet help them understand the importance of continued investment to prevent another crisis like Covid,” said Loyce Pace, the assistant secretary for global affairs in the U.S. Department of Health and Human Services.
The likely budget shortfalls may force hard choices: a narrowing of mission, or a honed focus on the countries most in need. Gavi, for example, currently buys vaccines for countries in desperate need such as Chad and Eritrea, but also for Kenya and Ghana, where health systems are stronger, and Nigeria, which has a booming economy.
The issue of debt will complicate this picture: As the donor-supplied global health budget shrinks, many countries that rely on it are struggling under huge debt burdens. African countries have borrowed at higher rates, on harsh terms that reflect their poor credit ratings. They are expected to spend $74 billion on debt service this year, more than all the global health funding combined. Ethiopia, for example, is spending $8 per capita on health and $26 per capita on interest on its debt.
The looming financial reckoning is intensifying a long-running debate among public health and development financing experts in lower-income countries — a debate that may soon echo in Washington: Are all of these multilateral agencies, set up to respond to crises, going to exist indefinitely? Do we still need them all?
Dr. Catherine Kyobutungi, director of the African Population and Health Research Center in Nairobi, argues that it’s time to transition away from agencies such as Gavi, which address just one issue, or the Global Fund, which tackle a few specific diseases. Instead, they say, global health funds should be channeled into building out national health systems, while countries buy their own vaccines or treat tuberculosis alongside other illnesses. New funds for pandemic preparedness should be used this way, too, they argue.
The donor funding that finances the big health agencies comes with agendas and priorities set outside the countries that ultimately receive the money, she said, distorting local markets and fracturing the response to health into individual projects.
For example, the Global Fund helped set up drug procurement, laboratory and outreach infrastructure for three infectious diseases in some countries, but there is nothing comparable for the noncommunicable diseases, such as diabetes and hypertension, that increasingly shorten lives in Africa.
“These institutions have really undermined the whole concept of the health system, the functioning of the health system,” Dr. Kyobutungi said.
Justice Nonvignon, a health economist at the University of Ghana School of Public Health in Accra, argues that the current funding system means that countries that depend on the giant international agencies don’t adequately fund their own health systems, while the market for goods like antibiotics and bed nets is warped by purchases made in Washington or Paris.
He and other critics say the looming sharp decline in donor funding for global health may accelerate change within these institutions. “We’re overdue for fundamental reforms in these institutions — and maybe this is when the conversation starts,” said Bright Simons, a Ghanaian entrepreneur who advises development organizations.
