'Cataclysmic' aid cuts offer chance to rethink future, not recreate past

Global health has made tremendous gains over the last several decades. Now, in what many describe as a cataclysmic event for aid funding, the goal should not be to recreate or resurrect those gains, but rather to rethink what they should look like in the decades ahead. That’s the argument Neil Buddy Shah, CEO of the Clinton Health Access Initiative, made at a recent Devex Pro Briefing on how today’s aid cuts will shape tomorrow’s global health sector. Citing his favorite statistic, Shah pointed out that in 2000, the average life expectancy of someone born in Malawi was around 42 years. “In just one generation, 25 years later, the average life expectancy of someone born in Malawi today is something like 64 years old. And that is tremendous,” he said. “And so we need to hold [onto] that huge accomplishment of what we’ve done collectively as a community, but also not try to keep tacking back to, ‘Well, we gotta recreate what happened.’” “I think this is a moment to fundamentally rethink what needs to come next, so that when we look forward another 25 years from now, we can say, ‘Global health is done,’ basically mission accomplished — someone living in Malawi lives as long as someone living in Japan and we’ve achieved parity in long life expectancy across the world,” he added. It’s a boldly hopeful vision, but Shah hasn’t lost sight of the current reality of widespread aid cuts — the effects of which he says haven’t been fully felt yet. On the one hand, “there’s been enough money still in the system from the last budgetary cycle and from all of these heroic efforts that ministries of health are doing to release emergency funds and that other NGOs are doing to … to keep essential services going.” On the other hand, “there are going to be massive reductions in expenditure, and that’s going to directly flow through to negative patient outcomes. And of course, we want to mitigate that as much as possible. But the reality is that there is a multibillion-dollar gap in global health financing that is going to hit over the next two to four quarters,” Shah predicted. In the immediate term, CHAI is talking to dozens of ministries of health to help them get their bearings in this time of “confusion,” Shah said, noting that he’s seen three trends emerge from those conversations. One, there are significant efficiencies to be gained, even for programs that are already cost-effective. “Some of these are really straightforward reforms,” he said. “Instead of having a four-day training in person, where most of the people have already done that training multiple times, you switch it to a one-day hybrid training.” Two is prioritization. “So if you have less money in the budget overall, really using that as an opportunity to say, ‘Can we move budget line items for things that aren’t lifesaving … and move it towards actually buying critical commodities,’” Shah explained, noting that Burkina Faso recently shifted $7 million from nonessential trainings and workshops toward procuring maternal health commodities and contraceptives. And third: “Who pays for everything going forward?” “I think that the sustainable financing piece is the hardest part of it,” Shah said, arguing that creativity and nuance will be critical. That means separating countries that can increase health spending on their own from those with high debt burdens and low tax bases that need more time to wean themselves off foreign aid. It also means increasing the creative use of capital from multilateral development banks and boosting the number of bankable projects that development finance institutions can invest in. “We just need to start being able to think in a different way, to bring those big, investable ideas to a fundamentally different type of funder,” he said. Another untapped resource? Philanthropy. “The wealth creation of the richest 5,000 individuals in the world is growing at a trillion dollars a year, so they can’t even spend it fast enough, and it dwarfs aid spending — and there’s an intent to spend that money,” Shah said. “I think philanthropy has a massive role to play here, and the big challenge for the global health community is to create ambitious and realistic enough, investable opportunities so that that money gets off the sidelines.” Technology, especially artificial intelligence, can also play a catalytic role in this era of doing more with less. It’s a subject Shah knows well, given that he also serves as chair of Anthropic AI’s Long-Term Benefit Trust. “It's not lost on me that there are all these cuts and a total reimagining of global health at the same time as there’s this extremely new, powerful technology that’s going to affect everything from drug discovery to diagnostics to clinical decisions,” he said. “The question is: Will it be like many other technologies, where there’s a 10-to-20-year time lag from when they’re used for the most transformational things in high-income countries versus when they get deployed in low- and middle-income countries? Or is there an opportunity to use this technology to leapfrog … high-income countries?” A further question is how to incentivize AI companies to focus on health. “We want to be able to take advantage of the most powerful models for the most important problems on Earth, and some of the most important problems on Earth are: How do you reduce disease and suffering in low- and middle-income countries? And that’s not going to happen by default right now,” Shah said. Rather, it’s going to take nudging and incentivizing “the OpenAIs, Googles, and Anthropics of the world to be building the product in a way that is going to solve some of the problems in low- and middle-income countries,” Shah added. Ultimately, however, the future of global health has to be country-led, he argues. That includes coming up with market-shaping strategies, such as how to entice big pharma to offer cheaper medicines. “When CHAI did market shaping early on, it was a little bit easy, because you had the Global Fund, you had PEPFAR, [you had] these big procurers that can guarantee a huge volume of sales to pharma, so pharma had the confidence say, ‘OK, we’ll produce millions of this drug at a low price point.’” Now, Shah says, that strategy needs to shift. It can still include the Global Fund to Fight AIDS, Tuberculosis and Malaria and PEPFAR, albeit on a smaller scale, but it also must include large country procurers pooling their budgets to give pharma that same confidence. “In the early days, we created these informal buyers’ clubs between different developing country governments, and that was able to provide the market stability to pharma to do low prices and high volumes. And so I think we need to return to some of the very early days of global health and think much more creatively around how do you still signal that there’s a big market here for pharma, but do it in a way that’s much more country-led,” he said. “I think we’re still in a really dynamic phase where there’s a bunch of ideas floating around,” Shah added. “But we don’t have forever to figure out what the new system will look like,” he warned. Now, we must move from brainstorming, debate, and discussion mode over the next several months to a clear future vision for global health security and how to stabilize prices going forward, he explained. “Things are trending in the right direction in terms of activity, but I wouldn’t say that there’s … clarity and unanimity of what that new vision should look like.”