Over the past 25 years, the world has witnessed remarkable improvements in health. The number of children dying per year has fallen from 10 million to less than 5 million, and new cases of the world's deadliest infectious diseases have halved since 2000. Combined with domestic leadership and access to health innovations, unprecedented levels of international financing and philanthropy have driven this trend and established institutions—including Gavi, the Vaccine Alliance (Gavi), the Global Fund to fight AIDS, Tuberculosis and Malaria (the Global Fund), the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and the U.S. President's Malaria Initiative (PMI).
But 2025's abrupt declines in donor funding threaten those hard-won gains and jeopardize this ecosystem. Acknowledging both the strengths and the flaws of the current system, we look ahead and call for practical yet transformative reform that centers on the following principles:
Reframing of health: Health should be a national development and infrastructure priority.
Country-driven priorities: Global health institutions should be positioned as instruments that support nationally defined and regionally agreed-upon priorities. Regional entities are well placed to shape priorities, but a precise division of labor is needed, outlined in clear mandates and mission statements as agreed upon by regional bodies.
Efficiency and equity: Reform must generate better value for money, reduce the administrative burden, and redefine return on investment in terms of health outcomes, system performance, affordable innovation, and sustainability. Expertise is widely available in most countries, which need fewer costly foreign consultants.
Preservation of global public goods: International funding for global public goods and against global threats should be preserved and even strengthened. These include data and surveillance, norms and standards, research and development (R&D), equitable access, pooled procurement, and epidemic preparedness.
Consolidation should be a means, not the goal
Institutional excellence and accountability: Organizations need to be assessed for capacity, critical mass, and adequate human and financial resources. Sunset clauses for most institutions should be included for their termination once mandates are achieved or entities merged.
Complementary financing: International funding should complement domestic investment and support a transition pathway for heavily debt-burdened countries.
The result should be an ecosystem with fewer but better coordinated institutions that have clarified mandates, a critical mass of human and financial resources, stable funding, and synergies that ease the burden on countries. Consolidation should be a means, not the goal. Mergers carry financial, human, and operational costs, and are typically rarer in international organizations than in the private sector. Shared back-office functions and country offices should improve efficiency and impact, particularly for resource-constrained ministries.
However, consolidation will only be beneficial where missions are clearly aligned, synergies are created, and bureaucracy does not worsen.
The Need for Drastic Reform
Low- and middle-income countries (LMICs) have long called for greater efficiency, equity, and a drastic overhaul of global health governance. Those desires were raised at the African Leadership Meeting on Investing in Health in 2019; at Africa's New Public Health Order Call to Action in 2022 [PDF]; and at the Accra Summit on Africa Health Sovereignty in August 2025, with the launching of "Accra Reset." Donors, including the leadership of the Global Fund and GAVI, are also advocating for reform. The rise in noncommunicable diseases, substantial demographic changes, and climate stress compound the need for change.
Failure to act now will only prolong countries' dependency on unstable foreign aid, and a short-term, cost-containment response will not be sufficient. Hoping that international funding will return to previous levels underestimates the profound transition that international development assistance has entered.
A more robust health ecosystem requires a clear-eyed assessment of the role and relevance of the global health architecture. Mandates, governance arrangements, and accountability mechanisms should be examined for their fitness for purpose. Debates on reform need to begin from the perspective of what countries and regional bodies require, rather than from the needs of existing institutions.
Reform efforts need to re-center national priorities on the health agenda. Primary health care (PHC) should be the default organizing principle. When governments lead on defining priorities and PHC-centered strategies, partners can play a complementary role, filling gaps, supporting innovation, and providing global public goods in ways that reinforce, rather than fragment, country systems.
Change in a world of shrinking development assistance for health (DAH) should involve more than "doing the same with less." Health should not be treated as a stand-alone "aid sector" but as an outcome of choices in health interventions, infrastructure, education, jobs, digital systems, governance, and R&D and manufacturing, such as Nigeria's Presidential Initiative for Unlocking the Healthcare Value Chain. The accelerating digital and AI revolution offers further opportunities to modernize health systems.
The risks of such reforms, however, are real. Funding for specific diseases, humanitarian aid, and marginalized communities, such as populations affected by HIV, could further decline and leave more people vulnerable to disease.
Strengths and Weaknesses of the Current System
At the turn of the millennium, a devastating HIV/AIDS pandemic, frustration with ineffective existing institutions, donor demands for new channels, and a surging interest in innovation provided a strong rationale for establishing a plethora of global health institutions. International funding was instrumental in driving major wins in global health, particularly in disease-specific programs against HIV, tuberculosis (TB), malaria, and neglected tropical diseases.
Multilateral development banks with social protection and employment programs also advanced health outcomes through investments in infrastructure, energy, water, and education. If executed well, DAH can both strengthen national health systems and improve outcomes, as illustrated in Rwanda and Ethiopia, where DAH was integrated with national reforms and primary care platforms to reduce maternal and child mortality. Similarly, both the Global Fund and PEPFAR invested in laboratory infrastructure, supply chains, and community platforms, sharply cutting HIV, TB, and malaria deaths globally.
Yet DAH still represents a relatively modest but vital share of the health expenditures in low-income countries and an even smaller share in middle-income countries.
DAH—from multilateral and particularly bilateral sources—has also had unintended negative consequences. The most obvious include inefficiencies and high overhead costs, a dependency on imported products, and a bypassing of national priorities, systems, and R&D agendas. But it can also fragment national health systems through its volatile and vertical financing, and access to the data that internationally funded projects create is often limited. Finally, it sets incentives for chronic underinvestment in health systems—including government investments.
Opportunities for Reform
In the spirit of the Accra Reset, we propose rational approaches to reform global health institutions that are outlined below; however, compromises could still be needed.
UN system entities
UN agencies need to refocus sharply on their core mandates.
In addition to reforming the funding model and governance of the World Health Organization (WHO), actors should refocus on the agency's core mandate and prioritize normative and standard-setting roles; data and surveillance; epidemic response and coordination; and convening power. That shift requires the WHO to step back from conducting research and operational interventions and to take a greater role in setting research priorities and monitoring technology developments. The mandate and size of country and subnational offices of the WHO should also be revisited.
The UN Children's Fund (UNICEF), the UN Population Fund (UNFPA), the World Food Program (WFP), and the UN Development Program (UNDP) play vital, but broader, roles in health. In addition to the UN80 report by the UN Secretary-General, which proposes a number of structural efficiency gains and mandates a refocus on procurement and humanitarian crises, the UN system's human resources model should be reviewed to reduce disproportionally high staffing costs and politicized appointments.
Global Health Financing institutions
Gavi and the Global Fund have each made major contributions to health and will remain necessary to support immunization and HIV, TB, and malaria programs in the poorest countries. Those programs, however, face inefficiencies that predate the decline in donor support and that place an administrative burden on recipient countries.
To reduce this burden and alleviate other inefficiencies, financing institutions should form a holding company with a single governance and secretariat, and several operational entities that work on substance and program implementation is a logical model. Such a model is common in private companies but not yet in international organizations. An example in the international NGO sphere is the HealthXPartners holding, including Population Services International and the Elisabeth Glaser Pediatric AIDS Foundation, and, on the multilateral side, the Bioversity-Center for Tropical Agriculture Alliance, established in 2019. This approach, using harmonized funding, granting, monitoring, and evaluation processes, could also host the Pandemic Fund, Unitaid, and the Global Drug Facility for TB. The expensive Geneva presence should be minimized.
Unitaid accelerates access to innovation but has more limited resources. A merger with a GAVI–Global Fund holding mentioned earlier would likely enhance its impact.
The Pandemic Fund uses domestic co-funding with international institutions as intermediaries to finance pandemic preparedness. To be more effective, the fund should integrate with the consolidated GAVI–Global Fund holding. In any case, the fund's future should be reassessed before the end of its lifespan in 2030, if not sooner.
Multilateral development banks (MDBs) are sources of health funding and are likely to regain importance. The Group of 20 has called for serious MDB reform [PDF]. Aligning the World Bank with global health institutions is equally important, as the two are often disconnected, creating further inefficiencies. Besides lending, blended financing and co-investment can support health infrastructure, digital systems, and innovations, while reforms should consider debt and fiscal space.
The Global Financing Facility could leverage World Bank international development assistance and support broader health services, offering incentives for health systems and primary care.
Disease-specific programs
The separate single-disease entities that were created at the start of the millennium—such as Roll Back Malaria and Stop TB—are no longer justifiable and should instead become key functions within the WHO and GAVI–Global Fund. Closure of UNAIDS by the end of 2026 is proposed by UN80, with functions shifting to the WHO, UNDP, and the Global Fund. Global and regional civil-society platforms need to be considered.
Product Development Partnerships
A multitude of product development partnerships have been created to accelerate innovation for infectious diseases that lack market incentives. Although some of these partnerships have delivered new products, many lack critical mass, and competition for declining funds is intense. The partnerships also underuse growing R&D capacity in LMICs. Given that market forces are unlikely to consolidate the product-development partnership ecosystem, funders should consider mergers and resource-sharing to increase value for money and impact. Greater LMIC involvement in governance and execution is essential, and creating an upstream holding company could harmonize development and share resources among different partnerships.
The Way Forward
The agendas proposed above may seem overwhelming, but failing to address the need for profound change will ultimately be more paralyzing. Parts of these proposals have been attempted previously with limited success, but the current momentum presents a new opportunity. The following 10 considerations can guide reform initiatives.
1) Be proactive, rather than wait for an acute crisis. Reforms should be managed responsibly with a clear focus on the core needs of countries, while containing the costs of change.
2) Co-create reform with key constituencies, connect with emerging initiatives, embrace leadership from the Global South (e.g., The Accra Reset), involve all major funders, and move away from overly academic proposals to concrete action.
3) Define clear timelines for action, not just meetings. Use 2026 for strategy and planning, and aim for implementation by 2027 or 2028.
4) "Coalitions of the willing" are likely to be more effective than individual governing boards, which are traditionally reluctant to make drastic reforms. Ultimate endorsement by global and regional political bodies will be crucial.
5) Use the momentum to change an individual institution or sector rather than try to change the whole ecosystem at once.
6) Frame domestic investment in health as a national development priority, essential for a reformed global health ecosystem. Health should be funded by domestic revenues and development banks, with DAH reserved for transition and global public goods.
7) Ensure continuity of essential services, in particular in humanitarian and epidemic crises, and disease-specific interventions. This will require uninterrupted operational capacity.
8) Balance trade-offs; while consolidation and country ownership are key, international support remains vital for biosecurity, emergency response, and preparation, innovation, and access to innovation.
9) Engage constituencies, as GHIs have committed supporters and advocates, while avoiding being derailed by vested interests.
10) Consider simultaneously the role and possible reforms of regional institutions, and the balance between global and regional approaches. Regional pooled procurement such as the PAHO revolving fund, and an African Pooled Procurement Mechanism, can be effective as long as multiple funds do not generate higher prices.
Within the next three years, a transformed ecosystem could be fully operational, re-energizing global health efforts.
The past 25 years show what is possible when resources, leadership, and innovation converge. The next 25 will require a system that empowers countries to build sustainable health infrastructure, confront security threats, and share innovation breakthroughs. The challenge is immense, but the opportunity is greater: to create a global health order that is not only more resilient, but also more just.
AUTHOR'S NOTE: We acknowledge with thanks the excellent research and writing support from Sarah Curran and Hannah Herzig, and inputs from Corine Karema and Mayowa Alade, as well as the numerous conversations with stakeholders around the world. A more extensive report, "Transforming the Global Health Ecosystem: Lessons Learned and a Vision for the Future," is available on Accra Reset.
