A Time for Change: Reforming the Global Health Architecture

The global health landscape is more fragmented than ever. A growing number of organizations and initiatives has created an overly complex system for health financing that is overburdening countries. Further, the system is proving increasingly unsustainable amidst constrained budgets that are unable to keep pace with growing needs.

Taken together, these realities underscore the need for a more effective global health architecture. A growing number of initiatives have begun to articulate these challenges and explore opportunities for reform, including the Africa Centre for Disease Control and Prevention’s (CDC) vision for a New Public Health Order and the Lusaka Agenda, among others.  

At the Center for Global Development (CGD), we (alongside collaborators) have long been engaged in research to unpack these challenges and identify policy solutions aimed at reforming this architecture. This blog summarises prior CGD work on diagnosing the key challenges facing the global health architecture, and summarises options for incremental and foundational reform. You can explore analyses, recommendations, and past events, here.

CGD does not take institutional positions and, indeed, we as authors of this piece will differ on specifics underlying specific policy proposals. However, stepping back, we see three broad themes that characterise our view on global health financing reform:

• Quality of support is at least as important as volume of funding. It’s all too easy to focus on dollars spent, but what it was spent on, how it is allocated and administered, and what plans there are to be able to continue such spending, is crucial. As external assistance for health comes under increasing pressure, there is an opportunity to focus on improving the overall quality, efficiency, and impact of available resources.
• A re-conceptualisation of aid, rooted in new narratives, that centre country priorities and institutions is overdue. In sometimes subtle, but often powerful ways, the current architecture of global health dominates national institutions. Priorities are set in Geneva, Washington D.C., London, Seattle, etc. Countries are asked to “cofinance” donor-funded health products and programs, not the other way around. The headlines for progress achieved in aid-recipient countries often foregrounds external donor contributions when doling out credit, even while domestic financing is greater than external aid in most recipient countries. Delivery through parallel supply chains and through international non-governmental organisations can side-step public systems. For a new era in global health, donors and external actors must do more to reimagine and redefine their role in a changing global landscape.
• Take both a short- and long-term view, charting out a clear vision for the future. Yawning gaps in access to essential healthcare services may justify an initial approach from donors to first plug those gaps. This can result in real and rapid improvements in lives saved and illness averted. However, it is crucial to bring the long-term perspective along for the ride and to protect hard-won gains, advance universal health coverage, and strengthen health systems. Beyond sustainability around financing health services and products, investing in strengthening core functions of the health system is essential. And this approach should also be reflected in the practice of development partnership between donors and country institutions. For example, developing structures to take a sector-wide approach, to focus on marginal support that complements country activities, and to move support on-budget where possible.

Building on earlier CGD efforts, we are currently working on a range of projects to advance these goals. Below we summarise key pieces of recent work under three themes:

1. Diagnosing the problem

Our first theme focuses on identifying the challenges and inefficiencies within the current global health system, especially as they relate to financing challenges and to transitions away from donor support.

• Country Transition Projections up to 2040: Gavi, the Global Fund, and the World Bank’s IDA. This analysis projects when and how countries might transition from key global health funding sources over the next two decades, highlighting challenges and opportunities for sustained impact post-transition.
• 2024–2025 Replenishment Traffic Jam Redux: Are Donors Getting into Gear? – With multiple funds seeking funding in the same cycle, this blog and interactive dataset examine the resulting challenges amidst competing demands on increasingly constrained resources.
• The Cost-Effectiveness of Health Aid: An Exploratory Quantitative Analysis  – This analysis evaluates the cost-effectiveness of current health aid, offering insights into where aid can achieve the greatest impact.
• The Bread and Butter of Global Health Financing – Identifies challenges with approaches to co-financing.
• Making Dollars and Sense: Conditioned Domestic Financing in Global Health – A piece which outlines potential pitfalls with conditioned financing from donors.
• The Future of UK Global Health Policy: Challenges and Opportunities – This analysis finds that rising non-communicable diseases and increasing focus on global health threats such as pandemics, climate change, and antimicrobial resistance requires a new, integrated and even multi-sectoral approach from funders and the global health initiatives.

 2. Incremental shifts for a fairer, more efficient system

The second theme includes work which proposes incremental changes to improve global health financing and operations, particularly among key global health initiatives like Gavi, the Global Fund, and WHO.

• Redistributing Power in Global Health: A Survey of Options for Donors – This piece assesses options for shifting power dynamics in global health funding to empower local stakeholders and drive more sustainable outcomes.
• Are Global Health Funds Falling Behind on Financial Innovation? – Here, we explore whether global health funds are keeping pace with new financing mechanisms that could enhance their reach and effectiveness.
• WHO Financing in 2024: Climbing the Ladder to Flexible Funding or Sliding Down Snakes? – This blog reviews WHO's current funding structure, advocating for more flexible financing options.
• Five Ideas for the Future of Global Health Financing: The Road Not Yet Taken  – A blog outlining five ideas for reform, from increasing domestic financing to establishing a permanent international coordinating body for health and finance.

We also have recently released a series of papers focused specifically on Gavi reform:

• Gavi Needs a New Playbook to Deliver Impact in a Changing World
• After Graduation, How Do Gavi-Eligible Countries Fare?
• Beyond the “Gavi-Eligible”: High-Leverage Opportunities for Gavi to Enhance Vaccine Access and Uptake in Ineligible Middle-Income Countries
• Projections of Eligibility and Transition Trajectories up to 2040: Implications for Gavi’s Next Strategic Period and Beyond

 3. Fundamental changes: envisioning the global health architecture 2.0

Our third theme covers work which connects to deeper structural reforms, envisioning a redefined, more collaborative global health system. As mentioned above, the leading visions for wholesale systemic change are Africa CDC’s vision for a New Public Health Order and the Lusaka Agenda. Here we include work to date that either more comprehensively supports these visions or presents proposed frameworks that imply deeper changes to our ways of working than the marginal reforms outlined above.

• Tracking Delivery on the Lusaka Agenda – This tracker monitors commitments made under the Lusaka Agenda, reinforcing the importance of accountability in achieving global health goals. If fully implemented, the Lusaka agenda would be transformational. The risk is it end up being marginal if only a few elements are implemented.

One tool in the box towards achieving more ambitious reforms is a collection of works which propose a New Compact between donors and aid-recipient countries. We recognise this New Compact is in some respects a fundamental change. Still, there may be opportunities to apply it flexibly, in the right contexts while accommodating constraints on some donors.

• Reimagining Global Health Financing: How Refocusing Health Aid at the Margin Could Strengthen Health Systems and Futureproof Aid Financial Flows  – Here we introduce the core concept whereby health financing is organised around country-led evidence-informed priority-setting. Domestic financing then covers the core package of services with aid focused on a top-up package or cross-cutting support.
• A New Compact for Global Health Financing: Could Countries and Donors Rewrite the Rule Book on Health Aid? – This blog introduces a follow up set of papers building on the original proposal and responding to feedback.
• A New Compact for Global Health Financing in Ethiopia ­– A case study of what New Compact scenarios could look like using data on health benefits package prioritisation in Ethiopia.

As global health challenges grow increasingly complex, we must seek both immediate improvements and long-term reforms. We invite you to explore our full collection of work on these themes, each offering unique insights into how we can create a more effective, equitable, and sustainable global health architecture.

Stay tuned for more, including analyses digging deeper on these issues, events featuring timely discussion and debate, and new policy ideas and proposals on how to reform the global health architecture. Make sure you’re signed up to our newsletter and bookmark the new topic page.