Transforming the Global Health Ecosystem: Lessons Learned and a Vision for the Future

Key Takeaways

• The global health ecosystem is at a breaking point. A rapid decline in donor funding threatens to reverse decades of health gains, making reliance on past funding levels unrealistic and unsustainable.
• Past success masks structural weaknesses. Despite over $880 billion invested in development assistance for health between 1990 and 2019, the system remains fragmented, inefficient, and overly dependent on donor-driven, disease-specific programs.
• Health must be reframed as a development priority. Health should be treated as national infrastructure and a macroeconomic investment, not a discretionary social sector expense.
• Country ownership must replace donor dominance. Global health institutions should support nationally and regionally defined priorities, with a clear division of labor between global, regional, and country-level actors.
• Efficiency and equity are non-negotiable. Reform must reduce administrative burdens, consolidate institutions where appropriate, and redefine return on investment around health outcomes, system performance, and sustainability.
• Global public goods still require international funding. Areas such as epidemic preparedness, surveillance, R&D, market shaping, and pooled procurement remain legitimate and essential uses of international finance.
• Domestic investment is central to long-term sustainability. Development assistance for health should increasingly complement domestic financing, with international support focused on transitions, fragile settings, and global threats.
• The window for reform is short. The authors propose 2026 for planning and coalition-building, with implementation targeted for 2027–2028 to avoid paralysis and preserve momentum.

Executive Summary

This report examines the evolution, achievements, and growing limitations of the global health ecosystem over the past 25 years. While unprecedented progress was achieved in reducing child mortality and infectious disease deaths through domestic leadership and development assistance for health (DAH), the system now faces a structural crisis driven by a sharp decline in donor funding and persistent inefficiencies. The authors argue that the current model, characterized by fragmented institutions, vertical financing, and limited country ownership, is no longer fit for purpose. They call for a fundamental paradigm shift that reframes health as a core national development and macroeconomic priority, financed primarily through domestic resources.

Global health institutions should be repositioned as catalysts rather than drivers, with a sharper focus on global public goods, efficiency, and accountability. The report concludes that timely, coordinated reform over the next three years is essential to preserve health gains, strengthen resilience, and build a more equitable and sustainable global health order.