What’s broken in global health, and how do we fix it?

For years, several experts have argued that the global health architecture is in dire need of reform and criticized the sector for its fragmentation and reliance on donor-driven agendas. Now, with donor funding cuts exposing cracks in the system, those calls have taken on new urgency. The abrupt withdrawal of funds — notably from the United States, global health’s biggest funder — led to the closure of numerous vital programs and organizations, curtailing access to essential health services for many individuals. Major global health entities were also forced to downsize and reevaluate their priorities. As a result, what has long been a simmering conversation about reform is now a pressing question: Can global health build a system that is less fragmented, less donor-driven, and more resilient to political shifts? Why the need for change? Wellcome CEO John-Arne Røttingen wrote in a blog post in July: “The old global health system has not been working for some time now. Despite many initiatives and institutions improving health and saving lives, half the world – around 4.5 billion people – still don’t have access to basic health services.” Commentators have repeatedly pointed to the same structural flaws. They argue that there are too many organizations with overlapping mandates that work with limited coordination, leading to inefficiencies. Donor-funded programs are mostly focused on specific diseases instead of strengthening health systems in countries to allow them to address different health challenges. Most importantly, the agenda is often set by donors rather than countries themselves, misaligning priorities with national needs. The COVID-19 pandemic reinforced these weaknesses. Despite decades of global health funding, many low- and middle-income countries still lack sufficient resources to respond to such health crises. Their reliance on other countries also led to inequities in access to lifesaving treatments and vaccines. What needs to change? For Norway, one of the biggest donors to global health, ensuring money is spent well and achieves the “most effective results” remains of utmost importance. However, “In a challenging geopolitical landscape with less funding for global health, now more than ever we have to look for opportunities for the global health initiatives to work in partnership and to better align and integrate their activities in accordance with national health plans and priorities,” Minister of International Development Åsmund Aukrust told Devex. He said this should be in line with the Lusaka Agenda, which was the result of a monthslong process that involved funders, government representatives, global health organizations, and members of civil society discussing the future of global health initiatives. The agenda aims to address some of the challenges in global health, such as addressing health inequities, improving coordination among global health initiatives, and focusing on national ownership of health agendas. “We expect all the global health initiatives to make their operations and administration more efficient, collaborate better, and remove duplicative functions both at global and country level,” he said. A spokesperson of the German Federal Ministry for Economic Cooperation and Development said that though the current global health architecture “has been extremely successful,” including in halving child mortality and doubling life expectancy, it needs to evolve. “We need to carefully analyze two things: First, what are the needs of the future? And, second, how can we best address them in the most efficient way?” the spokesperson said. That includes analyzing which functions and “actors” are needed, and building on those that work well instead of creating new entities. The spokesperson also underscored the need to eliminate duplication and enhance coordination among different organizations, as well as ensuring the financial independence of partner countries, “to ensure sustainable health systems and reduce reliance on external aid.” “These changes are vital to make the global health architecture better prepared for future health crises. This is very important, as we know that there is the good chance of another pandemic happening within the next decade,” the spokesperson said. Some of the recommendations and proposals made by different health leaders and experts seem to echo the same shifts. Catherine Kyobutungi, executive director of the African Population and Health Research Center in Kenya, wrote about the need for a reimagined health system where “domestic institutions control priority-setting and resource allocation and where external support reinforces rather than replaces national capacity.” Shadi Saleh, founding director of the Global Health Institute at the American University of Beirut, wrote that the system needs to shift power to regional and national actors, and proposed the establishment of a Middle East and Central Asia CDC. Others want more democratized governance with stronger roles for governments, regional institutions, and civil society from low- and middle-income countries. Neil Buddy Shah, CEO of the Clinton Health Access Initiative, spoke of a future that’s country-led, such as in drug procurement, where country procurers pool their budgets and make bulk purchases at lower prices. With the reductions in grant funding, others are also calling for increased taxation for certain products, such as tobacco and sugary beverages, and the use of blended financing to fill health budgets. Some had more controversial proposals. Experts at the Center for Global Development argued for the World Health Organization to focus on its global functions and pull back from providing country-level technical assistance and humanitarian services. While Olusoji Adeyi, president of Resilient Health Systems and former director at the World Bank, as well as other experts, have called for sunset strategies for global health initiatives. Making change a reality Some organizations have described their plans for changes. Sania Nishtar, the CEO of Gavi, the Vaccine Alliance, said the organization is shifting from eight grant windows to just one as part of efforts to ensure its processes are not burdensome on countries. Other leaders are taking a different approach, proposing a set of questions for countries and organizations as they develop a vision for a new global health system. Among them: “How should global health actors be arranged at the country level to avoid duplication of work?” and “With reduced levels of funding, when and how should transitioning out of financial support happen for lower-middle income countries as GDP per capita increases?” according to an article that appeared in Nature Medicine co-authored by Røttingen and other health leaders. Some experts also provided practical steps on how the sector can move forward with their recommendations. Kyobutungi proposed a road map for reform, starting with the redesign of Africa’s health systems. Saleh proposed doing preparatory work identifying the scope, structure, and governance of a proposed CDC for the Middle East and Central Asia, and a high-level meeting for its adoption during the second to third quarter of 2027. Wellcome said it has commissioned regional partners to hold dialogues regarding global health reform, and that it will hold a high-level global meeting on the topic in 2026. The big question, however, is which of these recommendations will gain the necessary political traction, including from the United States, which has expressed interest in creating new institutions outside of WHO? In recent years, there’s been a lot of talk about the Lusaka Agenda. Norwegian development minister Aukrust said they are “actively discussing with other donors how to make the most out of less, and how to support the implementation of the Lusaka Agenda” through board representations in WHO, Gavi, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, in collaboration with civil society and NGOs. The recent Accra Initiative declaration — a communique issued at the Africa Health Sovereignty Summit in August in Ghana that saw the participation of several African leaders and called for a reimagined global health order — doubles down on many of the Lusaka Agenda’s goals, particularly on global health aligning with national priorities. It also includes the creation of a high-level panel to discuss a framework for a “reimagined global health architecture.” Dr. Githinji Gitahi, CEO of Amref Health Africa, however, said nothing will change unless countries, particularly in Africa, achieve program sovereignty. Both the Lusaka Agenda and the Accra Initiative underscore the same principles they’ve been calling for at UHC2030, a global movement to build stronger health systems for universal health coverage, he said. It also refers to the same principles under the Paris Declaration on Aid Effectiveness, adopted in 2005. “It is a cry for sovereignty, but it will only be achieved when the power shifts, and that power needs to shift by program sovereignty,” he told Devex. “Because when you talk about money, the person with the money will tell you what they want you to do. But if you have program sovereignty and say, this is the way we do things here … [and] when you bring your money, know that if it’s outside this, you will not apply it here,” he added. He said this is possible and has been done in Rwanda. Furthermore, Dr. Mary-Ann Etiebet, CEO and President of Vital Strategies, said it will be important to invest in building local data systems for evidence-based decision-making and to build trust. “I am a believer in enabling governments to make decisions around how the investment should be spent. But again, they’re not able to do that if they don’t have a holistic view of the data. [And] from a funder perspective, data provides trust,” she told Devex. “I think trust has been an issue that has prevented donors from moving away from vertical programming to supporting governments around their strategic plan,” she added. Reforms, however, will require the involvement “of all relevant stakeholders: from the global south and north — public and private sector, civil society, academia and philanthropy,” and need to happen alongside reforms at the United Nations, according to the German ministry spokesperson, who said Germany is engaged in several processes pushing for a new global health architecture.