Transforming Global Health to Maximize Impact and Accelerate Self-Reliance
The last two decades have seen extraordinary progress in global health: tens of millions of lives saved, sharp reductions in mortality, and dramatic increases in life expectancy in even the poorest countries.
Yet the context has changed. Donors are cutting aid budgets. Implementing countries want to take the lead. Communities are demanding more agency. The model that has delivered such progress will not be the model to take us forward.
To adapt, we must transform the global health ecosystem, making it more efficient, more responsive to countries, and more integrated and innovative.
Just over 20 years ago, the Global Fund partnership was created to fill a glaring gap in the existing system. Combining the strengths of governments with the passion of communities, the reach of civil society, and the pragmatism of the private sector, this unique private-public partnership has proved extraordinarily successful, saving 70 million lives and cutting the combined mortality rate of AIDS, tuberculosis and malaria by 63%.
Now we must reinvent ourselves again: squeeze more from every dollar, support countries on their path to self-reliance, and contribute to the broader transformation of the global health ecosystem.
Maximizing the Impact of Every Dollar
Maximizing the impact of every dollar means ensuring rapid and affordable access to life-saving innovations. That is what we are doing with lenacapavir, the new, 100% effective, long-acting injectable HIV prevention tool. For the first time in history, this new HIV prevention drug is going to be rolled out in low- and middle-income countries and in high-income countries at the same time. The first deliveries in Africa take place this month. A generic version, further lowering the cost, will follow quickly.
We have taken a similar approach with the latest generation of mosquito nets to fight malaria, which are 45% more effective than traditional nets and cost only 70 cents more, and with AI-enabled digital X-rays, which facilitate advanced TB screening in some of the most difficult and remote environments.
Working with partners, we can move even faster. In delivering lifesaving innovations, time equals lives. Scale equals impact. We cannot afford years of pilot programs or slow rollouts.
But innovations only improve health outcomes if they reach those who can benefit most. Unaffordability, weak health systems, stigma and discrimination all remain formidable barriers. Overcoming these barriers is not just a matter of health equity and human rights; it is an epidemiological and economic imperative. If innovations do not reach those at highest risk, we lose impact and waste resources.
Maximizing the impact of every dollar also means dismantling health product and disease silos. A more integrated, people-centred approach, that tackles infectious diseases alongside noncommunicable conditions and mental health, can deliver better outcomes and save money – if well executed. Integrating multi-pathogen capacities into disease-specific interventions also strengthens our frontline defenses against emerging health threats. For the Global Fund, such shifts have profound implications. We must work with partners to reshape program design and delivery, without diluting the focus on disease outcomes.
Continuous improvements in efficiency are also essential. With operating expenditure at about 6% of disbursed funds from donors, the Global Fund is already highly efficient, but by leveraging technology, including AI, to further streamline and automate processes, we are lowering costs by a further 20%, while reducing burdens on partner countries.
Accelerating the Path to Self-reliance
Sharp cuts in external funding underscore the imperative for countries to accelerate their path to self-reliance. Yet this is a journey, and not an immediate switch. Too abrupt a transition will derail progress, and cost millions of lives. Countries’ readiness for transition differs enormously.
The Global Fund will partner with countries to accelerate their journey to self-reliance – supporting, incentivizing, and, ultimately, getting out of the way.
That’s why we have revamped transition planning and co-financing. For some countries, we will agree on a transition timetable that makes this three-year grant cycle their last. For others, the path to transition may take two grant cycles. For all but the very poorest and conflict-afflicted countries, we will work with governments to develop robust transition plans.
To support transitions, we are stepping up our support to countries to reinforce their public financial management systems and tap new sources of finance. We have already executed 14 Debt2Health swaps and 14 blended-finance transactions. We are directly supporting the development of national health insurance schemes in several countries.
We can also help countries sustain access to quality-assured affordable medicines by making it easier for them to use our pooled procurement mechanism with their own money. Transitioning countries often pay far higher prices and incur significant transaction costs, but these can be avoided by leveraging our global scale and digital procurement platform. By offering pre-financing and working with regional procurement platforms, we give countries more options.
Of course, there are countries where a combination of economic distress, conflict and governance weaknesses, plus the scale of the disease burden, make the transition to self-reliance a more distant prospect. Yet even in these contexts, we need to put greater emphasis on sustainability, helping build the systems and capacities that will be the foundation for the future.
Development assistance for health remains essential – to beat the deadliest diseases, support countries on the path to self-reliance, and strengthen global health security. Countries that have benefited most from globalization also have a responsibility to invest in global public goods such as health – not just out of generosity, but out of self-interest. Yet we need to be smarter in how we combine grants, domestic fiscal resources and private capital to create pathways to self-reliance.
Transforming the Global Health Eco-system
The Global Fund was born of disruption – out of a belief that the established ways were too slow, too bureaucratic, too detached from the front line. That same restless energy must drive us now.
To adapt to the new realities, the Global Fund is committed to making significant changes: cutting our costs, simplifying how we operate, becoming more responsive to countries’ needs. We also recognize that the global health ecosystem as a whole must be transformed, and that we must play our part in making this happen.
For all its successes, global health has become far too complex and fragmented, with duplication and bureaucracy creating challenges for countries and undermining impact. We must rationalize the architecture – merging or closing agencies where appropriate, clarifying roles, and changing the way we work together and with countries.
As the largest multilateral funder in global health, both for the three diseases and health systems in general, the Global Fund has assets that could be leveraged more widely – for example, our market-shaping capabilities, our global procurement platform or our unique role in strengthening community systems for health. Yet how the Global Fund evolves in terms of mandate and priorities should not be determined in isolation, but as part of a broader vision for the future of the global health ecosystem, encompassing the WHO, Gavi, disease-specific entities like UNAIDS, product development partnerships like Unitaid and CEPI, and our engagement with the World Bank and other multilateral development banks.
Switching to bilateral approaches is not the answer, since this will fuel complexity and undermine efficiency and effectiveness. Strengthening our multilateral system is the best option – but only if we are prepared to make tough choices. Given the inevitable resource constraints, we must be rigorous in determining where external funding adds most value, and how best to divide roles between agencies, based on comparative advantage. How we go about this matters. The transformation of global health cannot be dictated from Geneva or New York, but must reflect the leadership of countries and communities, plus regional bodies like the African Union.
From Disruption to Reinvention
The progress on global health over the last two decades has shown what the world can do when we come together. With scepticism, nationalism and more transactional approaches dominating the debate, the facts – tens of millions of lives saved, sharp reductions in mortality, massive increases in life expectancy, huge economic benefits – are a compelling reminder that thinking big, and acting together, can deliver extraordinary results.
Yet the model that has worked so far must change. The progress of the past 20 years stands as one of humanity’s greatest public health achievements. The next 20 will test whether we can be as bold in reinventing the system as we were in creating it.
The choice is stark: evolve or erode. We must adapt to new realities, and do so courageously, protecting what has made success possible, without being trapped in the past. Above all, we must remain committed to our goals – saving lives, ridding the world of the deadliest infectious diseases, and building health systems that deliver health for all and make us all safer. When humanity stands together, no challenge is insurmountable.
This op-ed was originally published on Forbes.