Why global health funding cuts offer an opportunity for reform | News

Despite significant progress against individual diseases like polio, malaria and HIV/AIDS, and increasing coverage of specific interventions like vaccines, more than 4.5 billion people still lack access to basic health services, with progress stagnating since 2015. One in four people globally face financial hardship due to health costs.

The Covid-19 pandemic exposed the fragility of the global health system and of global solidarity. The World Health Organization (WHO) estimated 14.83 million excess deaths globally in 2020-2021 alone. The pandemic led to cumulative economic losses of US$13.8 trillion, according to the International Monetary Fund. And it revealed the power imbalances that underpin global health, illustrated by stark disparities across research, development and manufacturing for tests, treatments and vaccines, which fostered lasting distrust across nations.

Financing projections are concerning too. Of 177 countries around the world, domestic health finance over the coming years is expected to contract in 41 and stagnate in 69 low- and middle-income countries compared to pre-pandemic levels.

There’s also less money to spend on health due to slow growth. Pressures from rising energy and food costs, climate damage and escalating debts services have added to this. After a sustained spotlight on health during the pandemic, many countries have turned to competing priorities.

And while many health ministers are under pressure to cut spending, demands increase. The need for strong and resilient health systems that can adapt to emerging threats such as climate change and conflict, while also maintaining coverage for existing health needs, is growing.

Strengthening these health systems requires every dollar to be used as effectively, efficiently and equitably as possible. But we continue to see highly fragmented international health financing. 

Many parallel funding streams exist that continue to focus on single diseases, rather than creating the most effective system. This creates high transaction costs, reduces overall efficiency and places unsustainable burdens on countries. It poses challenges to integrated service delivery and country ownership. Money is too often channeled towards priorities based on donor interests rather than country needs. 

Together this means that global health funding isn't as effective, efficient and equitable as it should be.

In response, marking the culmination of a 14-month multi-stakeholder process, the Lusaka Agenda proposed coordinated action to speed up progress towards domestically-financed health systems and universal health coverage that leaves no one behind. 

Since its launch, the Lusaka Agenda has gained increasing traction at country, regional and global levels, leading to positive shifts in alignment and coordination of global health funds that could translate to the much-needed enhanced efficiency and impact in countries.

In 2024, donors such as the EU, Germany and France announced sizeable aid cuts.

A new US administration led to the abrupt halt of significant global health funding in 2025, which is having an even more profound impact.

Dr Gerald Manthalu, a health leader from Malawi, shares in a personal perspective: "While the sudden nature of these reductions is disruptive, resulting in significant setbacks for health outcomes, a critical question arises: would the system have reformed without such a shock, and would it even be allowed to reform now?

"The incentives for change within the development assistance model have historically been weak, as entrenched interests, persistent power imbalances and inefficient practices have endured for decades."

The decline and disruption in global health financing has already had direct health impacts on millions of people. For example, a WHO rapid survey across 108 low- and middle-income countries found the nature and scale of service disruptions comparable to those observed during the peak periods of the Covid-19 pandemic in some settings. Cuts have also disrupted the functions and structures of critical institutions such as the WHO.

The stakes are high and an honest reflection and radical rethink of the global health system is now needed. What should be its key function and form over the next decades? What are the reform pathways to make this possible?

Recent shifts present an unprecedented challenge, but also a long-awaited opportunity to inspire a significant evolution of the global health architecture. The Lusaka Agenda is an important starting point for the wider reforms that are now needed. Reforms that could transform global health cooperation and lead to much-needed improvements in equity, efficiency and sustainability.

The collective response to this opportunity for reform would benefit from:

• ensuring country voices, priorities and leadership drive the conversation and decision-making around the future global health architecture
• prioritising coherence; as global health financing discussions increase, it will be critical to think and act holistically, uniting everyone involved behind common and ambitious priorities
• involving finance leaders from the outset, strengthening the often-neglected link between the health and finance sectors
• delivering a rapid response with a long-term, inclusive perspective, where locally led analysis from all regions informs a globally representative new system

Building on our support for the Future of Global Health Initiatives process, we are well placed to help advance inclusive discussions on global health reform.

Over the coming months we will complement wider country and regional processes by commissioning five proposals from individual thought leaders in Latin America and the Caribbean, Africa, Asia and Pacific, Europe and North America, and the Middle East and Central Asia that boldly reimagine the global health architecture.

These initial proposals are intended as a starting point for broader and more inclusive conversations, first at regional and then at global level. By doing so, we hope they will build agreement and action that bridges a moment of challenge and opportunity in global health.