Transforming global health financing in an uncertain world

As donor support fades, countries are exploring new strategies to support their health systems. This year’s World Health Assembly highlighted an urgent push for locally led solutions and the unlocking of new sources of funding.

The global health financing landscape is shifting, leaving many health systems under-resourced and overstretched. Photo: USAID Flickr

How can low- and middle-income countries (LMICs) sustain their health systems as donor aid dries up and domestic budgets come under increasing pressure? This question took centre stage at the 78th World Health Assembly in Geneva, shaping formal debates and informal conversations.

From pooled insurance schemes and regional procurement to health taxes and concessional loans, ministers, multilateral agencies, and civil society explored new financing models to help countries build stronger, more self-reliant systems.

Despite a shared call from governments, donors, and civil society to rethink how the world pays for care, no silver bullet was found. What did come through clearly, however, was the determination of many LMICs, especially in Africa, to pursue more bottom-up, locally driven responses to long-standing health system challenges.

“We're going through a dual crisis: countries are facing a major health financing challenge, and so is the World Health Organization (WHO).” — Kalipso Chalkidou, director of health finance and economics at the WHO

And the clock is ticking. A quarter-century of progress is now at risk of unravelling. What began with the optimism of the United Nations Millennium Declaration in 2000, fuelled by a surge in foreign aid, the creation of institutions like The Global Fund and Gavi, the Vaccine Alliance, and sharp gains in child survival and epidemic control, has entered a period of deep uncertainty. Since the peak of pandemic-era spending, official development assistance for health has fallen from US$84 billion in 2021 to just US$65 billion in 2023.

Washington's decision to pull the plug on its contributions to global health programmes is being followed by other countries, and major donors are also scaling back support, triggering a sudden shortfall that is already destabilising the fragile systems many countries rely on to maintain basic health services.

"We're going through a dual crisis: countries are facing a major health financing challenge, and so is the World Health Organization (WHO)," says Kalipso Chalkidou, director of health finance and economics at the WHO. "The vision for sustainable and equitable financing is universal health coverage but getting there requires significant time and resources, and right now, both are in short supply."

In the global south, where universal health coverage remains largely out of reach, governments are grappling with shrinking fiscal space, soaring debt repayments, and mounting economic headwinds. More than three billion people now live in countries that spend more on servicing debt than on health or education. Meanwhile, domestic health budgets are stagnating or being cut, a sharp reversal of the momentum built over previous decades.

"The financial crisis is having a significant impact on the Democratic Republic of the Congo, especially when you consider that, outside of Ethiopia, we were the second-largest beneficiary of US funding and the reduction in those funds is going to have a major effect on service delivery in the country," says Dr Polydor Kabila from the National Council for Universal Health Coverage in the Democratic Republic of the Congo.

The Lusaka Agenda: A blueprint for resilience

Faced with a deepening health financing crisis, many countries are turning to the Lusaka Agenda for guidance. Though developed ahead of the current downturn, it provides a relevant framework for action. Launched on Universal Health Coverage Day in December 2023, the agenda outlines five strategic priorities: strengthening primary health care, boosting domestic investment, improving coordination among global partners, expanding local manufacturing, and embedding equity in decision-making. Revisiting and advancing the agenda has become more urgent than ever for most of the LMIC representatives interviewed for this story.

“This isn't about patching holes anymore. We're talking about rewiring the system, with equity and local leadership at the core.” — Rosemary Mburu, executive director of WACI Health

"This isn't about patching holes anymore," says Rosemary Mburu, executive director of WACI Health, an advocacy organisation in Kenya. "We're talking about rewiring the system, with equity and local leadership at the core."

The Democratic Republic of the Congo is one of the countries quickly moving from planning to action. Starting next August, the country will begin collecting mandatory health insurance contributions: 2% from employers and 0.5% from employees in the formal sector, with efforts underway to include the informal workforce. This new domestic revenue stream is expected to help offset recent cuts in international funding. Authorities are also working to redirect existing taxes on tobacco, alcohol, and sugary drinks toward health financing, particularly for immunisation, as the country continues to battle outbreaks of vaccine-preventable diseases.

The international community, despite recent challenges, continues to support these efforts. "We're trying to maintain technical support to countries through our country offices, regional offices, and headquarters with normative guidance, technical assistance, and capacity building. But our capacity to deliver is shrinking, even as demand grows," explains Chalkidou of the WHO’s contribution.

One example of coordinated action is the UHC Knowledge Hub, a collaboration between the WHO and the World Bank, supported by Japan, which works directly with ministries of health and finance to build shared competencies and strengthen the case for health investment.

"The shrinking availability of funds directly affects our ability to respond effectively, which is why we're now prioritising core functions. Helping countries navigate their own financing crises is a top priority for us," Chalkidou says.

Scaling up domestic investment and capabilities

In the aftermath of Covid-19, countries around the world recognised the urgency of building stronger domestic capabilities. Today, many governments are exploring how to channel more financing into areas that have long depended on support from the global north. Even the WHO is undergoing reforms to clarify its role in this shifting landscape. Together, these developments aim to bring the global community closer to the vision outlined in the Lusaka Agenda, one that strengthens health systems through a more balanced model, leveraging domestic resources and expertise from the global south.

"There is hope that mechanisms like World Bank financing will empower governments to invest in their true health priorities," says Professor Charlotte Watts, executive director of solutions at the Wellcome Trust. "I've been impressed by how countries are stepping up to fill the gaps. As scientific capacity grows in the global south, we're increasingly focused on ensuring that southern partners play a central role in the innovation efforts we support."

The Global Fund, also facing financial challenges, is doubling down on efficiency and domestic co-financing to protect decades of progress. "Maximising the impact of every dollar has been core to our model since day one," a spokesperson explained, pointing to its emphasis on country ownership and mandatory co-funding as key tools for long-term sustainability.

With traditional aid shrinking and fiscal space tightening in many partner countries, The Global Fund is working closely with national governments to strengthen financing strategies and scale up domestic investment. Still, as the spokesperson notes, not every country can transition at the same pace: "It's a pathway, not a switch." Debt, conflict, and weak health infrastructure make accelerated self-financing impossible for some countries, particularly in sub-Saharan Africa.

The Global Fund and Gavi, the Vaccine Alliance are working together to streamline global health efforts. Photo: The Global Fund/Rooftop

The Global Fund's size and multilateral reach have allowed it to significantly influence the global health market, driving down costs for antiretroviral drugs and TB diagnostics, and rapidly deploying next-generation malaria nets.

To avoid duplication and streamline efforts, it coordinates closely with Gavi, the Vaccine Alliance, the WHO, and Unitaid, while exploring administrative integration in areas like translation services. It is also investing in public financial management support to help countries track budgets, improve accountability, and sustain donor investments.

Facing a more fragile aid environment, The Global Fund is seeking to increase private sector contributions by nearly 50%, targeting US$2 billion for its next replenishment, and deepening collaborations with companies around innovation, logistics, and AI. It is also working with institutions like the World Bank to co-finance health systems, particularly in the context of climate vulnerability, and backing debt-swap initiatives in countries like Indonesia and Cameroon to convert debt repayments into domestic health investment.

Investments filling the funding gap

Some governments are struggling to fill the funding gap and reallocate domestic resources to maintain service delivery. This is where multilateral development banks (MDBs) have recently become important actors. "We provide long-term financing, such as policy-based loans, results-based loans, or investments in infrastructure and workforce development. These are larger-scale investments that align with national budgets, rather than acting as external aid," says Akihito Watabe of the Asian Development Bank (ADB).

ADB is stepping up its role in health system reform across Asia, shifting from isolated projects to comprehensive national strategies. In the Philippines, for example, ADB has committed US$1.5 billion in policy-based loans to support reforms across the Department of Health and PhilHealth, the country's national health insurer. Similar efforts are underway in Indonesia with BPJSK (Social Security Agency for Health), and in Bangladesh, where ADB is financing local vaccine manufacturing, a model it is looking to expand despite regulatory and intellectual property challenges.

Countries like Ethiopia, Kenya, and Rwanda are no longer alone in grappling with how to maintain essential health services under shrinking budgets. In Japan, authorities are struggling to sustain the quality and scope of care within what citizens are willing, or able, to pay.

Since the pandemic, ADB's health investments have grown substantially, rising from just 3–4% of its portfolio pre-pandemic to 6–8% today, with plans to reach 10%, a trend similar to other development banks. These funds support public health financing, private investment in health providers and pharmaceutical manufacturing, and innovation. The bank is also exploring co-financing partnerships with institutions like The Global Fund, Gavi, the Vaccine Alliance, and the World Bank, combining loan-based models with grant funding to stretch limited resources and strengthen domestic ownership.

Asian Development Bank is ramping up health investments and partnering with funders like Gavi, the Vaccine Alliance. Photo: Gavi/White Rhino Films - Lameck Orina

What was once a challenge concentrated in LMICs is also now a global crisis: fiscal pressure on health budgets is tightening worldwide. Countries like Ethiopia, Kenya, and Rwanda are no longer alone in grappling with how to maintain essential health services under shrinking budgets. In Japan, authorities are struggling to sustain the quality and scope of care within what citizens are willing, or able, to pay.

"There's some solidarity in the pain right now across the world," says Professor Margaret Kruk, adjunct professor of health systems at the Harvard T.H. Chan School of Public Health.

Kruk warns that political will remains a missing link in sustainable health financing. "We've made the mistake in health of ignoring politics for too long and when we push some policies bold and big, that's the last time we see the government that tried to implement them."

WHO's dual response to the shortfall

As health financing faces one of its sharpest contractions in decades, the WHO is adapting with a dual strategy: reinforcing its technical core while unlocking new sources of funding through private partnerships.

"We have no choice but to be both more focused and more catalytic," Chalkidou says. With government budgets under pressure worldwide, the WHO is prioritising its traditional strengths—norm-setting, data, and technical assistance—while helping countries restructure national health priorities and stabilise fragile systems.

But it is the WHO Foundation, established in 2020, that's playing a key role in filling critical funding gaps. Operating independently under the WHO's ethical framework, the WHO Foundation is building bridges to private capital, philanthropic donors, and corporate partners.

"We're not replacing public funding, but we are unlocking new investment in high-impact areas, knowing that it is unlikely that private capital will be able to replace official development assistance (ODA)," says Moz Siddiqui, director of partnerships at the WHO Foundation. "However, we do believe that the private funding, whether from philanthropies, the private sector, or even the general public, can be directed to critical areas where the WHO has a unique and comparative advantage."

With traditional aid flows shrinking, the WHO Foundation is turning to blended finance and outcome-based models, combining grants, loans, and private investment to support health systems, emergency response, and disease surveillance. Recent support has gone to HIV programmes, critical care in fragile settings, and measles and rubella monitoring.

Although concerns about private-sector influence persist, Siddiqui says the WHO Foundation adheres to strict governance protocols and screens partners to ensure alignment with public health goals. "No funding is accepted from industries like tobacco or arms," he notes.

From snakes to systems change

Across Africa, countries are putting the Lusaka Agenda into motion through grounded, pragmatic reforms. In Kenya, an unexpected public health challenge has become a catalyst for change: snakebites.

Each year, venomous bites kill over a thousand people, mostly in rural and underserved areas. In 2023, the Ministry of Health launched a national snakebite strategy, but rather than treating it as a niche concern, authorities framed it as a model for broader systems integration. With support from the WHO and NGO partners, the strategy embeds antivenom distribution, community training, and case tracking into Kenya's health strategy.

“This is not just about treating snakebites. It's about building domestic capacity—scientific, logistical, and manufacturing—that can serve the country for decades.” — Mary Muthoni Muriuki, principal secretary at the Kenya Ministry of Health

"It sounds narrow, but it's actually transformational," says Mary Muthoni Muriuki, principal secretary at the Kenya Ministry of Health. "It's a model for shifting vertical, donor-led programmes into something sustainable and government-owned."

The initiative also aims to reduce Kenya's reliance on expensive foreign imports. The government is exploring options to build local production facilities for antivenom, a move seen as both a health security measure and an industrial policy goal. "This is not just about treating snakebites," Muriuki says. "It's about building domestic capacity—scientific, logistical, and manufacturing—that can serve the country for decades."

This shift, anchoring externally funded health interventions within national priorities, is echoing across the continent. In the Democratic Republic of the Congo, a new digital dashboard now tracks health interventions across provinces for malaria control, helping reduce duplication and improve coordination with civil society and external donors like the Global Financing Facility.

"We're using malaria as an entry point," said one official during a recent regional panel. "But the goal is much bigger: building a system that works beyond just one disease."

Similar efforts are underway elsewhere. In Ethiopia, community-based insurance and digital health platforms are expanding coverage. Mozambique and Chad, two countries navigating sharp cuts in external aid, are working with The Global Fund, Gavi, the Vaccine Alliance, and the Global Financing Facility to integrate donor-funded services into national health systems gradually.

Underlying all these efforts is a recognition that top-down approaches are no longer enough. "Southern leadership isn't optional; it's the only way forward if we want systems that actually last," says Watts of the Wellcome Trust.

The role of the private sector

As public financing tightens, private actors are stepping up—not to replace governments, but to support national health systems under strain.

At the World Health Assembly, a growing number of public-private initiatives were at the forefront. WHO and member states reiterated the importance of strong safeguards to ensure that corporate partnerships and blended finance mechanisms align with public health goals. Advocacy groups like Oxfam urged caution, warning against a creeping "financialisation of global health" and calling for robust regulatory frameworks.

With input from South Africa, which holds the current G20 presidency, many are looking to Japan as a strong model of effective public-private partnership in health. Its unified public payment system ensures that both public and private providers deliver services under the same benefit package. "That’s one of the keys to maintaining equity, even with private sector involvement, " says Dr Satoshi Ezoe, Japan’s senior assistant minister for global health.

Some companies are positioning themselves as long-term partners in system strengthening. “Our clinical, technological, and business expertise helps us drive patient impact by supporting partners to develop projects that are bankable, that will pay for themselves, and that make sense in the larger socioeconomic context of each country,” says Elisabeth Staudinger, managing board member at Siemens Healthineers.

Operating in more than 180 countries, Siemens Healthineers is working closely with African governments to strengthen diagnostics, a critical but often underfunded component of health systems. “We’re not just delivering equipment. We’re helping build lab infrastructure, train staff, and co-design sustainable financing models,” Staudinger says.

By 2030, Siemens aims to reach 1.25 billion patients in LMICs and deliver six million hours of training to local health professionals.

Meanwhile, Sanofi’s Global Health Unit has taken a community-first approach across 40 LMICs, 25 of them in Africa. Its focus is on non-communicable diseases (NCDs) like diabetes, hypertension, and cancer, conditions often neglected in global aid agendas.

“We created the Global Health Unit specifically to work where unmet needs are highest,” says Jon Fairest, head of the Global Health Unit. “This sector is purpose driven. We avoid the politics and cycles of aid. What matters is delivering results.”

Sanofi currently supports more than 100 programmes worldwide in partnership with ministries of health, NGOs, and local distribution networks. These initiatives range from training community health workers to equipping rural clinics with diagnostic tools and patient education materials. "We train frontline workers to manage NCDs and refer patients when necessary. That’s how we reduce pressure on national systems and improve outcomes," Fairest says.

Beyond service delivery, Sanofi is investing in health entrepreneurship. Through its €25 million (US$28.5 million) Impact Fund, it has made eight equity investments in African health startups, providing capital and executive mentorship. “Governments often co-invest, and we track outcomes rigorously. Every programme has KPIs [key performance indicators] in place,” Fairest says. “We want governments to have skin in the game."

The 78th World Health Assembly laid bare the fragility of global health financing—and showcased a growing determination to adapt. From fiscal reforms to stronger private sector engagement, governments are beginning to take the lead, recognising that a healthy nation is a wealthy nation. With traditional aid in retreat, they can no longer afford to wait for solutions parachuted in from the global north.