The increasingly fragmented global health ecosystem is unsustainable and ill-equipped to strengthen country health systems and tackle disease.
Transformation is needed if we are to achieve universal health coverage (UHC). Yet, attempts to reform the system face several challenges, including:
- holding actors accountable to their commitments
- ensuring effective use and ownership of national coordination mechanisms
- developing monitoring systems that provide useful information without overburdening countries
The Covid-19 pandemic laid bare critical weaknesses in global health systems. However, it also opened a window of opportunity to renew focus on health financing gaps and prompt fresh scrutiny of the transition models used by global health initiatives (GHIs).
Now, we find ourselves at a new, and arguably more complex, crossroads:
Several major bilateral development donors have already paused or announced significant reductions in their health funding, with others expected to follow in 2025.
This trend signals a seismic shift in the global health funding landscape, raising urgent questions about the sustainability of programmes, the adaptability of health systems, and the future of international collaboration.
The need for innovative, resilient financing strategies has never been more pressing.
As the global health community seeks to navigate the evolving terrain, we must learn from past efforts. It is only by understanding what has worked, what hasn’t and why, that we can improve how the GHIs deliver. This is essential if we are to chart a more sustainable path forward.
Future of Global Health Initiatives
Future of Global Health Initiatives (FGHI) process aimed to reflect on how global health initiatives (GHIs) can be optimised to best support national health priorities and countries’ progress towards UHC.
FGHI brought together a group of global, regional and national health stakeholders (including governments, international- and domestic-financing partners, civil society, health organisations and academics) in a time-bound process of consultation and research throughout 2023.
Commissioned by the Wellcome Trust, Itad evaluated the FGHI process to generate forward-looking insights on what worked well and provide lessons for future global health exercises.
Our evaluation provides a record of what happened and the successes and challenges encountered. It is designed to support learning and reflection by the global health community and to inform future collaborative efforts.
Lessons for the global health community
In the context of US withdrawal from the international aid system and further cuts to the UK aid programme, these lessons learned are timely.
1. Define the problem clearly from the outset and leverage work of previous efforts
FGHI’s lack of consensus among stakeholders on problem definition highlighted the importance of achieving clarity early in the process. FGHI allocated insufficient time to agree the problem up front. As a result, while it disrupted the status quo, it is not clear that the process laid the foundation for lasting institutional change.
Instead, future work should invest time and resources in developing a shared understanding that is sufficiently grounded in evidence of what worked well/less well from prior efforts and is supported by a broad range of stakeholders.
2. Establish inclusive and transparent governance structures
Effective governance requires transparent, structured mechanisms for selecting participants and ensuring all relevant voices are heard. Balancing efficiency, inclusivity and legitimacy is crucial to foster credibility and trust.
Future efforts should mobilise effective stakeholder engagement via clear strategies that go beyond invitations to participate. Ensuring institutional backing for LMIC representatives and Civil Society Organisations (CSOs), as well as including and resourcing them meaningfully in decision-making processes, is essential for achieving balanced representation and fostering ownership of outcomes.
3. Driving change requires sophisticated, multi-layered political economy analysis of GHI Boards
The political economy of FGHI was dominated by existing, complex power dynamics which play out across GHI Boards and other health-related inter-governmental bodies.
Integrating political economy analysis early in the process can enhance the understanding of power dynamics, competing interests and institutional constraints. Such analysis is vital for designing strategies that effectively engage diverse stakeholders and navigate political complexities.
Future initiatives should consider designing governance structures that include formal mechanisms for GHI Board engagement from the outset, to secure buy-in, align institutional interests with reform objectives and enhance the feasibility of proposed solutions.
4. Capitalise on windows of opportunity to address fundamental issues in health financing
A new opportunity is now arising in 2025, spurred by major shifts in international funding. Declining international aid budgets underscore the urgency for innovative global and regional financing strategies, within a framework that facilitates cross-GHI cooperation.
Despite challenges, there is a growing appetite for reform. This will require joint accountability mechanisms to improve coordination between global and regional or national stakeholders.
Efforts must go beyond surface-level changes, to promote actionable frameworks that strengthen domestic funding, and integrate with other international mechanisms.
Rethinking the global health ecosystem to achieve universal health coverage is, as we’ve seen, a complex and interconnected process. To dive deeper into lessons from the FGHI process, download our full report here.
