The global health field is facing its most substantial transition in decades. Over the last 18 months, dramatic U.S. policy shifts—including the withdrawal from the World Health Organization (WHO), dissolution of the U.S. Agency for International Development (USAID), and the unveiling of new bilateral health agreements—have occurred alongside broader cuts to global health funding, resulting in a 20% reduction in global development assistance for health between 2024 and 2025.
Although pressure to reform the global health system began before the most recent disruptions, as the 2023 Lusaka Agenda demonstrates, momentum for reform has since accelerated. Several ongoing reform efforts are expected to offer recommendations in the coming year, including the Accra Reset and a WHO-led process on reforming the global health architecture. Also in the coming year, several key global health institutions, including WHO, the Africa Centres for Disease Control (Africa CDC), the Global Fund, the Coalition for Epidemic Preparedness Innovations (CEPI), and Gavi, the Vaccine Alliance, face leadership transitions, budget shortfalls, or both.
To inform ongoing reform discussions, the authors conducted a rapid review of recommendations on the future of global health since 2023. The methodological approach is described at the end of this article. Based on this review, consensus is emerging on a future global health system in which leadership and decision-making are less concentrated in high-income countries, investments focus on building stronger national health systems instead of disease-specific programs, regions increasingly take on roles historically played by global institutions, and donor funding focuses on strengthening national and regional systems.
Despite broad consensus on an emerging vision of a future global health system, three important questions remain on how to translate that vision into an effective, sustainable system: Should decision-making roles be tied to provision of funding? What are the consequences of shifting away from disease-specific models toward more integrated investments? What should be the role for global versus regional institutions? Ongoing reform discussions should focus on tackling those questions.
Publications on Global Health Reform Since 2023
More than half the 67 identified publications identified in this review are commentaries or op-eds, and the least common publication types were those from civil society organizations or policy journals.
The number of publications fitting inclusion criteria has increased substantially since the 2023 release of the Lusaka Agenda, especially following the announcement of U.S. withdrawal from the WHO and the dissolution of USAID.
The publications included in our review were written by authors located in Europe (31%), Africa (26%), North America (23%), and Asia (16%); less than 5% of authors came from other regions.
Most Common Recommendations on the Future of Global Health
Drawing on the included publications, the authors grouped 405 explicit recommendations into eight overarching themes, as shown below. The most common recommendations focused on shifting decision-making to countries and regions and aligning donor funding with country priorities, including to diversify sources of financing. Together, these two themes accounted for almost half of all recommendations, demonstrating an emerging consensus on the importance of shifting power from donors to countries and regions. Recommendations focused on specific topic areas within global health, including health security, were less common, indicating a focus on shifting how the system is structured instead of what it is focused on accomplishing.
Since 2023, as the number of publications on the future of global health has increased, the focus of the recommendations has evolved, mostly notably with a growing emphasis on shifting decision-making beginning in 2025. Other notable changes during this period include a decreasing focus on strengthening health systems and improving regional coordination—themes that have long been supported in the global health community—and increasing focus on consolidating global health initiatives and increasing domestic investment. These shifts in focus seem to reflect a growing recognition of changes to how the system has operated due to shifts in policy by the United States and other donors, and the development of a new system that is less dependent on those countries.
Although the top recommendations were fairly consistent across author regions, the order varied. For authors based in Africa, decentralizing decision-making was the most frequent recommendation, a regional prioritization that may offer a preview for the recommendations coming from African-led reform processes, including the Accra Reset. In Europe and North America, aligning donor funding and diversifying sources of financing was the most frequent recommendation, reflecting a vision that is perhaps more tied to the previous donor-led system. Meanwhile, consolidating global health initiatives (GHIs) was the least frequently raised by African authors (only 6% of the region's total) compared to authors from the other three regions, a notable difference given that most of the GHIs' work takes place in Africa. It suggests that the push for consolidation may be more about budgetary concerns from donors than from overlapping mandates in countries. Authors in Africa were less focused on improving regional coordination than authors in Asia and Europe, although recommendations were often focused on coordination in the Africa region.
What's Next? Implications for Reform Discussions
Together, the recommendations propose a new global health system that is ambitious and transformative, and our review suggests strong consensus on the principles that should guide it; 84% of recommendations were focused on the five top themes. However, our review also reveals several important unresolved questions that will need to be addressed in the next phase of reform discussions in order to translate those principles into reality.
Should decision-making roles be tied to provision of funding?
Half of all recommendations on the future of global health focus on a combination of decentralizing decision-making roles from global to regional and national actors, better aligning donor funding with country priorities, and, to a lesser extent, increasing domestic resources for health. However, assumptions about the relationship between shifting decision-making and the sources of financing were often unclear.
One exception is a 2026 paper by Muhammad Ali Pate and his colleagues, who argue in favor of reforms that recenter national priorities and focus on primary health care, and donor funding supplementing instead of replacing the core functioning of health systems. Rasanathan and his colleagues made a nuanced argument in 2025 for better alignment between the different types of global health functions, such as delivery and financing, and specific country contexts, such as humanitarian response versus more stable settings.
Alongside shifting decision-making roles, many authors call on donors to better align funding with national priorities and to channel investments through national systems; transition from short-term, project-based funding to integrated, long-term support; and make funding processes simpler and more predictable. Some authors connect these transitions in decision-making and donor funding to the need for increased domestic resources for health, through both better allocation of existing budgets and diversification of financing sources.
However, in many cases the focus of recommendations was on shifting decision-making without explicitly addressing the sources of funding. Overall, African authors recommended shifting decision-making to countries more than authors from other regions, yet mobilizing domestic resources was one of the least popular recommendations—just 11% of the total—across the four regions, especially in African countries. That may reflect different expectations about the relationship between financing and decision-making in the future.
As long as high-income countries continue to play a significant role in financing parts of the global health system, the leaders of those countries will need to justify how their taxpayers' money is being spent
Historically, decision-making roles have been closely tied to control of resources. Better alignment of donor funding with national priorities is feasible within that framework. However, consistent with the argument made by Pate and colleagues, the best way to sustainably shift power to countries and regions may be through increased domestic and regional financing for health. As long as high-income countries continue to play a significant role in financing parts of the global health system, the leaders of those countries will need to justify how their taxpayers' money is being spent. The same challenge arises with philanthropic or private-sector funding—it is nearly always tied to the priorities or interests of the donor. The next phase of reform discussions should be clear-eyed and explicit about assumptions regarding continued financing of national and regional systems by high-income country or other donors, and whether and how that funding should be linked with priority-setting and decision-making in the future.
What are the consequences of shifting away from disease-specific funding models?
Much of the discussion about the need to invest in and prioritize health-systems strengthening was posed in contrast to the disease-specific approaches that have dominated global health investments over the last few decades. Catherine Kyobutungi noted in 2025 that the post–Sustainable Development Goals era offers an opportunity to build a new African-owned agenda based on strengthening health systems, which will require better evidence on how to operationalize primary health-care frameworks. Although strengthening aspects of the health system has been deprioritized in the years since 2023, the theme remains popular particularly among African authors, many of whom focus on strengthening key aspects of the health system, including the workforce, data systems, and manufacturing.
The idea of moving from disease-specific silos to integrated health-systems strengthening has long had broad support, in principle. In practice, the global health field has functioned in disease-specific silos for decades, in terms of both donor funding and agenda setting, such as the Sustainable Development Goals and the Global Polio Eradication Initiative. The benefits of this approach include that disease-specific targets are often seen as more tangible and easier to track and therefore more effective at mobilizing donors and partners. One of the core successes of the U.S.-supported President's Emergency Plan for AIDS Relief (PEPFAR) program, in terms of public health impact and consistently high funding levels, has been its clearly defined outcomes, measurement, and reporting of progress.
Shifting to a focus on integration and health-systems strengthening will require a new approach to tracking progress, at the global, regional, and national levels, and could make government accountability more difficult for civil society organizations. Reform discussions should start outlining clearer timelines for transitions from disease-specific investments to health-systems investments, and they should clarify the areas where donor support would be complementary to national budgets. Donors will also need to grapple with how to build and sustain domestic political support for broader health-systems investments without tangible metrics to track progress. They will also need to decide how to navigate investments in countries where governments do not have the capacity or political will to make the necessary health-system investments.
What is the role of global versus regional institutions?
Another common recommendation focused on improving regional coordination. In 2026, Jean Kaseya and his colleagues proposed prioritizing African institutions in decision-making about issues affecting the region through enhanced voting rights in global institutions and expanded regional representation in cross-border surveillance, pooled procurement, and technical support during crises. Similarly, Ngashi Ngongo and his colleagues argued in 2025 that African regional institutions should take the lead on regional priorities, including evidence-based norms and guidelines, technology transfer and regulatory capacity, workforce strengthening, and resource mobilization.
Reflecting a core takeaway from the Lusaka Agenda, many authors recommended clarifying the mandates of GHIs to ensure that they are not duplicative and that they are consolidating their functions based on country-level needs to reduce inefficiency and administrative burden. Many emphasized the need for GHIs to refocus mandates on their comparative advantages and to better align budget cuts with clear adjustments to their strategies.
Implicit in both recommendations—and sometimes explicit—is an argument that regional institutions like Africa CDC should take over the role that has been played by WHO and global health initiatives. This raises important questions about who will fund regional institutions and whether they have the capacity to take on some or all of these roles. The top donors to GHIs are unlikely to simply shift their funding to regional institutions in the short term, in part because of questions about the core mandates and unique contributions of GHIs, including global surveillance, pooled procurement, and coordinated R&D, and clarity about which of those can or should be handed off to regional institutions. Decisions about the roles of WHO versus regional offices of institutions will need to be made by member states, but substantial shifting of responsibilities would logically raise questions about further shrinking WHO's budget.
One area where support appears to remain for global coordination—albeit through a more effective and sustainably financed model—is health security. Recommendations emphasized the need for international donors to invest in global public goods against global threats, including data, norms and standards, R&D, access, pooled procurement, and epidemic preparedness. Some also focused on the need for global cooperation to ensure equitable access to medical countermeasures during an emergency (4% across all regions, but 10% of recommendations from African authors). Several recommendations also focused on building manufacturing capacity and regionally aligned mechanisms, including regulatory systems and pooled procurement.
Takeaways
In some ways, laying out an ambitious vision is the easiest part of this reform process. The more difficult discussions about shifts in power and resources, priorities, and capacity of different institutions should come next. As ongoing reform processes consider their recommendations, many anticipated in the next year, they should grapple with some of the difficult tensions and trade-offs that will emerge from these changes and propose a feasible path forward.
Methodology
To conduct this analysis, the authors reviewed documents published to date since December 1, 2023—the month the Lusaka Agenda [PDF] was released—that propose concrete policy recommendations to reform global health systems, governance, architecture, or financing. Publications were identified across seven source categories: commentary and op-ed (including academic commentaries), think tank publications, multilateral and government publications, policy journal articles, civil society publications, foundation publications, and peer-reviewed academic journal articles.
Publications were removed based on preset exclusion criteria, including broad commentaries not specific to global health and those that recommended institution- or country-specific policies. The search was limited in several ways, including the exclusion of non-English-language results, and the use of search tools that may be biased toward U.S. and European authors. The authors also analyzed variations in recommendations based on publication type, year of publication, and author location. Commentaries and op-eds dominated the list of identified publications, but even with that category of publications removed from the analysis, the authors found a similar breakdown of recommendation themes overall.
AUTHOR'S NOTE: The authors will continue to monitor new future of global health publications and will update the piece as needed. Please send any additional publications that meet these criteria to [email protected] for inclusion in a future update of this analysis.
