The Trump administration has been considering a plan for reform at the World Health Organization, including putting an American in charge, in order for it to remain a member of the global health agency, according to two sources familiar with the plan and a proposal document reviewed by Reuters. The document, shared with President Donald Trump‘s advisors before his Jan. 20 inauguration, recommended that the United States quickly announce its withdrawal from the WHO and adopt a “radical new approach” for dealing with the agency, including pushing for a U.S. official to serve as director general when Tedros Adhanom Ghebreyesus’s term ends in 2027.

Trump’s executive order to exit the WHO was among his first policy moves upon taking office. It would lead the global health agency to lose its single-biggest funder by Jan. 2026. The order accuses the organization of mishandling the COVID-19 pandemic and being unduly influenced by other nations, which the WHO denies.

Trump has since suggested the U.S. could return if the WHO was “cleaned up,” without providing details on what that would require.

The reform proposal has been under discussion since before Trump took office, but it is not clear whether his administration will adopt any of its other recommendations, the two sources said.

The Trump administration “will continue to review current processes and healthcare bodies to implement needed reforms,” White House spokesperson Kush Desai said in a statement to Reuters. He did not comment on any discussions regarding WHO. Compiled by an outside policy expert at the request of Trump’s transition team, the proposal concludes that the WHO has become “the most chaotic, least effective UN agency.” The WHO has failed to execute on reforms proposed over the last two decades, leading to a deterioration in management and scientific expertise, the document says.

It acknowledges that leaving the WHO would hurt American interests but argues that the same is true of staying in the organization unless it is reformed.

WHO’s director of transformation, Soren Brostrom, rejected the criticisms in an interview with Reuters, saying that the agency has undertaken its most fundamental reforms to date under Tedros.

“We have reformed totally, and we know we are still in progress,” he told Reuters, citing moves to increase its independence from donors by reforming its funding model, giving more autonomy to country directors outside of headquarters and providing more transparency on spending.

The WHO’s work may be more complex compared to other UN agencies because of its wide remit, he said, but stressed that its responses to health crises were far from chaotic.

“If member states… have additional requests for reform, we will try to deliver,” he added.

Special envoy

The proposal document calls for the appointment of a U.S. special envoy in 2025, reporting to Trump and the White House, to oversee negotiations with the WHO about potential reforms prior to the exit scheduled for next year.

Currently, WHO coordination is handled by the State Department and the Health and Human Services Department. The envoy would push for a U.S. official to run the global health agency for the first time in its history.

“There is no formal reason why this is the case and the lack of American leadership at the top of WHO has been a critical factor in the wasting of American funds and the decline of the organization’s efficiency,” the proposal states.

Brostrom said any member state can propose a director-general and push for their candidate. The WHO’s executive board selects a short list of contenders and the candidate who secures at least two-thirds of member states’ votes is chosen for the role.

The United States is by far the WHO’s biggest financial backer, contributing around 18% of its overall funding annually, consisting of $400 million in voluntary contributions and $130 million in assessed contributions which are paid by member states based on the size of their economy. The WHO has warned of spending cuts unless other donors step in to fill the U.S. gaps.

The U.S. has already stopped collaborating with WHO, including a ban on communication with the U.S. Centers for Disease Control and Prevention, a long-time partner in identifying and curbing global disease outbreaks.

However, it has a delegation present at the agency’s executive board meeting, taking place Feb. 3-11 in Geneva, to determine the WHO’s upcoming budget and priorities, Brostrom said.

Last week, 43 U.S. lawmakers urged Trump to reconsider the exit plan for the health of Americans and the world. Public health activists are also seeking to halt the move, including potential legal action to challenge the decision.

“It would be in America’s best interests to remain and push for reforms,” said Lawrence Gostin, a professor of global health at Georgetown University in Washington and director of the WHO Collaborating Center on National and Global Health Law.