Opinion: How the world funds global health is starting to look outdated

For me, there wasn't a dull moment at the 79th United Nations General Assembly, but one moment in particular stood out because it touched on a highly consequential issue — and allowed me to share my controversial position on that issue. The ONE Campaign staged a debate to examine whether the golden age of global health replenishments is over, and I was firmly on the “it’s over” side. Even though my sparring partner from the ONE Campaign, Jenny Ottenhoff, did her best to maintain the nuance and rich factual texture of the question at hand, I went straight for the jugular as to why the current approach to funding the likes of the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance is doomed in the coming years. ONE is a strong supporter of the replenishments campaign, so it is testament to their open-mindedness that they wanted a debate on the issue at all. I reckon that most people in the global health community are gung-ho about the prevailing health replenishments model, which is why it is important to share some counterpoints to this broad consensus. A rich-government affair The global health replenishment model, which fuels initiatives like the Global Fund and Gavi, relies heavily on donations from a handful of wealthy governments. For instance, 94% of the Global Fund’s contributions come from governments, and this trend is consistent across other major global health partnerships. Yet, donor fatigue is setting in, as evidenced by several high-income countries like Austria, Finland, and Poland discontinuing contributions. Even prominent donors, including the United States and the United Kingdom, have fallen short on their pledges. Beyond these blips on the rich government radar, there are more critical issues. Private sector participation is long overdue One of the most pressing issues with the replenishment model is the low participation of the private sector. Private and nongovernmental contributors to the Global Fund account for the remaining 6% of all contributions — with nearly 80% of that from just the Gates Foundation. In contrast, private capital often plays a significant role in global development financing across many sectors, not just health. We see this particularly with multilateral development banks like the World Bank, which taps into private markets using government-backed guarantees. However, in the 77 years since the World Bank has been raising private money, it has never actually had to call on its rich government shareholders to make good those guarantees. Global health institutions have not fully explored this private capital financing path. If global health funds are serious about closing the financing gap — estimated at over $66 billion for Africa alone — they must find innovative ways to engage private investors. This would involve borrowing from private markets and paying back through well-designed treasury operations, similar to how development banks operate. The ‘solidarity’ model is looking passé One of the central tenets of the current model is solidarity, where countries — regardless of wealth — contribute what they can and receive funding according to need. However, this model is increasingly strained. Some middle-income countries, like India and Malaysia, remain eligible for Global Fund resources despite having the capacity to address health challenges themselves. Vietnam and Indonesia, which only recently transitioned out of Gavi funding, could and should have exited much earlier. For example, in 2014, Vietnam’s immunization budget was less than $80 million. Total health care expenditure over the period was over $14 billion. Effectively, vaccination spending accounted for just about 0.5% of total public health funding. The idea, therefore, that without Gavi’s intervention with free money in a place like Vietnam the government couldn’t pay is taking the solidarity logic too far. In addition, the $18 billion target set for the seventh Global Fund replenishment cycle (2023 – 2025) is starting to look overambitious — especially without pandemic solidarity to bank on. Nearly two-thirds of the way in, just a little over $5.2 billion of the $14.4 billion in pledges from the public sector have been redeemed. Funds targeting specific disease burdens is an outdated approach Another reason I believe the replenishment models are becoming something of the past is that they tend to focus on specific health challenges — such as vaccines or HIV/AIDS — often at the expense of broader health systems. Is it smart to limit the lowest-income countries to small amounts of money for vaccines and a few health interventions when these countries are thinking big — for example, by borrowing money from the likes of China to build water systems to provide clean water to their citizens? As the social determinants of health become more apparent — the conditions in which people live, including factors like socioeconomic status, education, access to health care, etc. that affect overall health — it's increasingly clear that narrow disease-targeted approaches may not be enough. Countries need more comprehensive financing to address the broader factors influencing health outcomes, such as water, sanitation, and health care infrastructure. While grants have been helpful in targeting specific issues, they are not enough to address systemic health challenges. Instead, concessional loans — which are long term and low interest — could unlock much-needed capital to fund integrated health interventions. Contrary to fears of debt crises in low-income countries, health is an investment that could boost productivity and, with good governance, generate returns that keep debt sustainable. The global health financing gap is widening, and the replenishments model is no longer sufficient to meet these growing needs. Governments are showing signs of fatigue, private-sector engagement is minimal, and the focus on grants is limiting our ability to tackle systemic health challenges. It’s time to rethink the approach, embracing innovative financing solutions that harness the power of private capital and concessional loans. The Global Fund and Gavi have together saved about 67 million lives to date. This is wonderful, but so much more could be done for so many more. It is time to expand their “resource imagination” so that they can be even more transformative. By embracing new methods, we can ensure that the global health community has the resources it needs to meet future challenges.