Yesterday brought big news for global health: The Global Fund’s board named Mark Dybul as its next executive director, bringing back a familiar name at a pivotal time. The Fund faces a roughly $5 billion replenishment shortfall, mounting pressure to balance donor demands with greater country ownership, and fundamental questions about its role in a changing global health landscape. At the same time, new technologies could significantly accelerate progress against HIV/AIDS, tuberculosis (TB), and malaria.
Dybul, who served as executive director from 2013 to 2017, brings deep institutional knowledge, experience navigating Washington as a former U.S. Global AIDS Coordinator and PEPFAR architect, and a willingness to challenge the prevailing global health system. He has called on global health institutions to abandon “organizational self-preservation” and support countries “as they shift from dependency to sovereignty.”
When he returns to the helm of the Global Fund in early 2027, the challenge will be turning that rhetoric into meaningful reforms—in line with the vision my colleagues and I outlined to “radically simplify” the institution.
Here are four priorities I’ll be watching closely.
1. Concentrate grants in the poorest countries and set wealthier ones on a realistic transition path
Scarce resources demand tough choices about where grants go. The Global Fund should protect financing for the poorest and most fragile countries while moving relatively wealthier countries toward responsible transitions from routine grant support.
Despite its sustainability, transition, and co-financing policy, Global Fund grant eligibility has remained relatively inclusive. As a result, 14 percent of disbursements have historically gone to upper-middle-income and high-income countries, even as some poorer countries struggle to fully finance their disease responses.
The secretariat’s recent move to introduce explicit transition timelines is a step in the right direction. But does the pace match today's funding realities? For example, Thailand and Kazakhstan can receive grants through 2030, while HIV and TB programs in South Africa have an even longer runway. (All three are upper-middle-income countries eligible to borrow from the World Bank on non-concessional terms.)
Yet success should not be measured solely by how many countries exit Global Fund grant support. Transitions take more than a fiscal handover; countries must assume responsibility for priority setting, procurement, and other essential health system functions. Where national delivery cannot adequately reach vulnerable populations, targeted, time-bound Global Fund support may still be needed.
The Fund could also support countries in other ways even after grants wind down. The board’s recent decision to extend access to the Wambo.org platform offers a promising path for countries to purchase health products using non-Global Fund financing, while complementing emerging regional procurement initiatives.
2. Reform how the Global Fund delivers support
The Global Fund has often relied on earmarked grants and parallel delivery structures that operate outside national systems. Even when disbursements are designated as “on-budget” and governments are labeled as “principal recipients,” funds may still be managed outside national budgets and governance structures (more details here).
These arrangements can be essential in fragile settings or where nongovernmental actors are better positioned to deliver health services. But they should not be the default where national systems can deliver effectively.
Moving away from rigid disease-specific earmarks would also give governments greater flexibility to set priorities across HIV/AIDS, TB, malaria, and supporting health system functions, while retaining accountability for disease-specific outcomes.
The new executive director should champion a leaner model that, where feasible, works increasingly through national budgets and gives countries greater ownership of priorities.
3. Test new financing models
Shrinking budgets also demand new financing models. For some middle-income countries, the Fund could explore loans on varying concessional terms. Joint financing arrangements with multilateral development banks could also unlock financing for health systems at greater scale and align external investments with national priorities.
Meanwhile, as traditional donor funding declines, new philanthropic resources—with a sharp focus on results and cost-effectiveness—provide another opening. The proposed Malaria Impact Accelerator, a new funding mechanism in partnership with GiveWell, would mobilize $2-3 billion in additional funding. This is exactly the scale of ambition the moment calls for.
But the proposed model also raises questions about disease-specific earmarking, governance requirements, and additional funding and application processes for countries. Such arrangements could, at times, pull the Global Fund in the opposite direction from efforts to simplify its model and strengthen country ownership. The next executive director will need to assess the trade-offs and balance these pressures in pursuing new partnerships.
4. Go bigger and faster to expand access to high-impact innovations
Despite uneven progress against the three diseases, there is reason for optimism: a promising pipeline of new technologies offers a major opportunity for the future—but only if they reach more people, faster.
The Global Fund's role in consolidating demand across countries, negotiating prices, and coordinating procurement can be vital for bringing new technologies to market faster and more affordably. As countries progressively take on a larger share of financing core disease programs, the Fund could devote more resources to newer, higher-cost technologies that are harder to finance domestically.
The Fund’s recent partnership with the US State Department to expand access to lenacapavir—a twice-yearly HIV prevention injection—is a promising start, even if modest relative to global need. The new executive director should build on this approach to scale new malaria treatments and prevention tools and, with Gavi, prepare for the rollout of new TB vaccines.
Dybul will have no shortage of priorities. But an early test of his leadership will be whether he can work with the Global Fund’s board to turn reform ambitions into meaningful change. He recently warned that the next 12-18 months will be critical for laying the groundwork for greater country ownership. His return to the Global Fund is the clearest opportunity yet to translate that urgency into action.
Thanks to Pete Baker, Erin Collinson, and Rosie Eldridge for feedback.
