The United States has historically played a central role in shaping global health governance, providing substantial funding, technical expertise, and leadership to tackle a range of health challenges across the globe [16]. However, recent developments, such as the potential withdrawal of U.S. leadership in global health through its actions with the WHO and USAID, suggest that the global health landscape may be undergoing a significant transformation. If the U.S. indeed steps back, the global health architecture will need to adapt to address emerging gaps while ensuring continued progress on critical health initiatives. Importantly, the idea that the U.S. would completely withdraw from global health leadership is more complex. Past crises, such as the 2020 U.S. withdrawal from the WHO (which was later rescinded), and the shift in focus to empowering institutions like the World Bank, have shown that while the U.S. may scale back from certain roles, it still asserts leadership through alternative avenues [17,18,19]. Nevertheless, this shift marks a departure from its traditional model of engagement, signalling the possibility of a reimagined global health governance system that may operate with less U.S. influence.
It is important to differentiate between “withdrawing from the WHO” and “withdrawing from global health leadership.” The former refers specifically to the U.S. distancing itself from one prominent international health body, while the latter implies a broader retreat from setting the global health agenda, which may not occur simultaneously. The decision to reallocate leadership from the WHO to organizations like the World Bank in the aftermath of the HIV/AIDS crisis reflects the U.S. strategy of reshaping global health governance rather than abandoning it entirely. Similarly, the closing of USAID offices in certain regions indicates that the U.S. may be withdrawing from specific areas but does not necessarily signal a total abandonment of its global health leadership role. However, these shifts raise the critical question of whether global health could be better off without the U.S. holding such a central role. The U.S. withdrawal from direct WHO involvement in 2020, for example, prompted increased reliance on regional actors and new collaborations, which may have, in some cases, offered more agile and contextually appropriate responses to health crises [8,9,10].
One significant consequence of diminished U.S. leadership could be the increased prominence and autonomy of regional health organizations. For instance, the Africa Centres for Disease Control and Prevention (Africa CDC), established to lead public health initiatives across the continent, has already begun to play a more assertive role in shaping health strategies that reflect African priorities and realities. This is not merely a possibility, but a trend backed by precedent. During previous moments of diminished U.S. engagement in global health such as during the early response to the Ebola outbreak in West Africa, African institutions and regional collaborations, including the Africa CDC and the West African Health Organization (WAHO), mobilized to coordinate responses, build surveillance systems, and establish emergency operation centres. More recently, in the face of COVID-19 and uncertain global leadership, the Africa CDC led continent-wide vaccine procurement through the African Vaccine Acquisition Task Team (AVATT), developed pandemic response guidelines, and pushed for local vaccine manufacturing capacity. These actions signal a broader shift toward regional health autonomy and strategic agency. As the future of U.S. involvement in the WHO remains uncertain, the Africa CDC and allied institutions are well-positioned not just to fill gaps, but to redefine the next phase of global health governance from a distinctly African perspective which keeps equity, sovereignty, and regional solidarity at its central focus [22]. Without U.S. guidance, these organizations could expand their scope and spearhead continent-wide initiatives to improve healthcare infrastructure, combat infectious diseases, and respond to emerging health crises. Decentralized governance could empower regions to design and implement health strategies more closely aligned with their unique challenges, fostering greater innovation and resilience. The COVID-19 pandemic, for instance, showed how critical regional coordination could be in enhancing preparedness and response, as countries in Africa rallied around Africa CDC to provide timely guidance and support. This trend could extend to other regions, with similar efforts being made by organizations such as the Pan American Health Organization (PAHO) in Latin America and the Asia Pacific Leaders’ Malaria Alliance (APLMA) in Asia.
The possible absence of U.S. leadership could also catalyse the formation of new global health alliances, particularly from nations in the Global South, who might advocate for more inclusive and equitable decision-making. These alliances could prioritize fairer health resource distribution, focusing on addressing health disparities that disproportionately affect low- and middle-income countries. Countries in Africa, Asia, and Latin America may unite to create coalitions aimed at influencing global health policies, ensuring that decisions consider the needs of the most vulnerable populations. These partnerships could also lead to increased investment in areas such as vaccine distribution, telemedicine, and digital health solutions. For example, the African Union’s recent partnerships to improve vaccine access have shown the potential for self-reliance in global health governance, and similar collaborations could emerge across other regions, with nations pooling resources, sharing knowledge, and creating regional hubs for research and innovation.
With the potential retreat of U.S. funding, non-state actors such as philanthropic organizations and private companies may step in to fill the funding gaps left by the United States [23]. As seen with organizations like the Bill & Melinda Gates Foundation and other global health philanthropies, private actors can play a significant role in driving innovation, funding health programs, and expanding access to life-saving resources. Global pharmaceutical firms and tech companies might also contribute by improving the supply chain, advancing diagnostic tools, and supporting healthcare infrastructure. However, while increased private sector involvement offers opportunities for scaling up health interventions, it raises critical concerns about accountability and equity [23] – [24]. The reliance on private interests could lead to interventions prioritizing commercial viability over public health needs, further exacerbating health disparities. To address these risks, frameworks for public-private collaboration should be established that emphasize transparency, inclusivity, and alignment with global health priorities. This would ensure that efforts to improve health outcomes are directed towards underserved populations, without compromising equity for the sake of profit.
Ultimately, the question of whether global health is “better off” without U.S. leadership deserves not just reflection, but critical engagement, particularly in the context of shifting power dynamics and emerging regional leadership. While the U.S. has historically provided substantial funding and technical support, its leadership has often been accompanied by geopolitical interests that do not always align with the priorities of low- and middle-income countries. The recent assertiveness of actors like the Africa CDC, the growing influence of countries such as China and India in global health, and renewed South-South collaborations suggest that a more multipolar approach to global health governance is both possible and perhaps preferable. A global health architecture less dominated by any single country may open space for more equitable, locally driven solutions. However, the risks of fragmentation, reduced funding, and weakened coordination also remain real. The challenge and opportunity lie in reimagining global health leadership not as the purview of one powerful actor, but as a shared responsibility rooted in collaboration, accountability, and mutual respect. While the U.S. has been a major force in advancing public health, its partial retreat could open space for new leadership models that may better reflect the diverse needs of the global health community. Regions and non-state actors could fill some gaps, but they would need to ensure that global health governance remains unified, responsive, and focused on the most vulnerable populations. By leveraging the strengths of regional organizations and non-state actors, global health governance could become more decentralized, more inclusive, and potentially more resilient in the face of future global health crises.