The global health system is facing a moment of reckoning. The cuts to foreign aid from the second Trump administration— along with withdrawals from key international partnerships, and the weakening of cornerstone agencies like USAID, CDC, and WHO—have put decades of progress at risk. At the same time, a broader political shift is underway, with donor countries increasingly pulling back from financing the global health system. Governments in France, Germany, and Sweden cut international development funding, unraveling the global safety net for vulnerable populations. The UK recently announced further foreign aid cuts to fund an increase in defense spending, while the outcome of Germany’s elections is likely to put additional pressure on foreign aid budgets.
This is not just a crisis of funding—it is a fundamental shift in how global health will be resourced and sustained in the years ahead. Across the global health community, people are feeling the weight of this shift deeply: most acutely in the communities served. Programs that once had stable funding are now in jeopardy. The UN is halving food rations for Rohingya refugees in Bangladesh; one of the only clinics on the Myanmar-Thai border has been closed, cutting off access to essential life-saving services; and a mysterious Ebola-like illness has broken out in the Democratic Republic of Congo, all following the cancellation of 90% of USAID’s international development projects. Colleagues who have spent their careers building critical health infrastructure are suddenly left without resources to continue their work.
At the same time, within global health itself, a long-running shift toward decentralization and localization has been gaining momentum. For years, practitioners, policymakers, and leaders have argued that the global health system must transition from a top-down, donor-driven model to one that empowers national and local health systems to lead. The sudden withdrawal of funding is forcing an acceleration of this transition—whether we are ready for it or not. This crisis has exposed the vulnerabilities of a system that was built for a different era and has now been outgrown.
Change is no longer optional—it is imperative. This moment must be used not just to patch gaps in funding, but to rethink how we deliver global health—decentralizing decision-making, integrating efforts, and ensuring that national and local actors have the power and resources to lead.
The Consequences of an Incomplete Shift
Historically, the overconcentration of decision-making power in global institutions and donor agencies has led to misaligned priorities, inefficiencies, and fragmentation. Competition for funding, rigid mandates, and lack of coordination across organizations have contributed to duplication, wasted resources, and fragile health systems that rely too heavily on external actors. Meanwhile, efforts to strengthen national capacity have often lacked the structural changes and political will needed to transfer leadership—they have failed to establish the robust foundations and local ownership needed for countries to sustain their own programs – leaving countries dependent on outside interventions rather than progressing toward self-sufficiency.
These flaws are not theoretical—they have played out in real time. When the Ebola outbreak struck West Africa in 2014, affected countries struggled to respond due to fragmented global health coordination. In Haiti, multiple organizations launched competing cholera response programs, wasting resources and creating service gaps. The COVID-19 pandemic further exposed the weaknesses of global health dependency, as delays in vaccine distribution left low- and middle-income countries waiting for a slow, fragmented, and insufficient response.
The current global health model is no longer sustainable. While effective in delivering large-scale impact, it struggles to reach the last mile. More critically, it remains deeply exposed to funding cuts, shifting donor priorities, and geopolitical instability. Unless the system evolves, we will continue to face cycles of crisis, where essential programs collapse every time political or financial conditions shift.
The Way Forward: Collaboration, Adaptation and Resilience
The global health system is unraveling before our eyes. We do not have the option to preserve it as it was. Instead, we must adapt, reshaping global health institutions to function as true partners in a locally led ecosystem.
The international community must take this opportunity to not only shift decision-making power and resources to national and local levels but to do so in a way that fosters cooperation, alignment, and collective problem-solving. The shift toward decentralization cannot simply be a reaction to shrinking donor budgets—it must be an intentional strategy that strengthens health systems in the long run.
Not insignificant is the additional challenge of funding. Beyond the political will to increase collaboration and streamline programming, financial support will be imperative to translate this vision into reality. We don’t have a solution yet: we must come together and chart a path forward to meet this challenge.
This is not about abandoning the institutions that have driven decades of progress, nor is it about resisting change out of fear of uncertainty. It is about leaning into transformation—building a global health system that is adaptive, responsive, and truly aligned with the people it serves.