ver 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.