A blueprint to empower countries in the Global South to end their dependence on health aid, which includes the possible closure of international global health organisations, was launched by the Accra Reset on the sidelines of the UN General Assembly on Monday.

“A national reset without a global reset leaves us building on shifting sand,” Ghanaian President John Mahama told an event to celebrate the first anniversary of the Accra Reset. “Likewise, a global reset without domestic discipline is unfeasible. They are two sides of the same coin.”

Mahama initiated the Accra Reset a year ago when he convened a meeting of African leaders in Accra to respond to the massive and immediate cuts to health aid implemented by the Trump administration. It has since evolved into a global platform pushing for the reform of global health and aid institutions, based on empowering countries and regions.

The Reset’s plan, A Sovereign Future For Health, notes that external financing for health in Africa fell by almost 70% between 2021 and 2025.

“For many countries in the Global South, the abrupt changes in the global health financing system require rapid response and adjustments that their fiscal structures are not able to accommodate in the short-term,” it notes.

The report outlines several steps to empower aid-reliant countries, starting with “one-stop country compacts” jointly led by the Ministries of Health, Finance and Planning, and including local stakeholders and “restructured”  international partners. 

Mahama stressed that meaningful country sovereignty requires accountable governance, not simply the transfer of decision-making power from international institutions to national authorities.

Strategic reform of ‘Big Five’ health bodies

However, it also proposes that global health institutions “whose main business is passing money, commodities and products to countries” should be “strategically reformed” immediately, in terms of ‘the 4Cs’ – “commit, collaborate, consolidate and close”.

First up are the five global health institutions that “account for the largest flows of funds and commodities and most of the burdensome processes experienced at country level”. 

These are Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the World Bank’s Global Financing Facility; the Pandemic Fund (also housed at the World Bank) and Unitaid.

However, it also notes that disease-specific partnerships “whose separate maintenance is increasingly difficult to justify” are on the chopping block, including UNAIDS, Roll Back Malaria, Stop TB, and the Global Polio Eradication Initiative (GPEI).

Also under the microscope are product development partnerships “where rationalisation, merger and sunsetting should be considered”.  These include the Medicines for Malaria Venture, the Drugs for Neglected Diseases Initiative (DNDi), the TB Alliance, the International Vaccine Institute, and the Coalition for Epidemic Preparedness Innovations (CEPI).

Gavi CEO Sania Nishtar told the launch that her organisation’s reform, the Gavi Leap, was focused on country sovereignty, country-centred approaches and stronger regional leadership. Gavi’s investment in the African Vaccine Manufacturing Accelerator is also aimed at supporting the move to regional independence.

Welcoming the report, Global Fund executive director Peter Sands said: “Accelerating the pathway to health sovereignty should not be equated with a retreat from global solidarity. This is a new form of partnership. Ultimately, the true measure of our success is the difference this makes to people’s lives.”

Guidelines for countries

The report outlines five steps to empower countries to move away from aid dependence. The first step is “practical sovereignty”, where countries “own the decisions, the financing framework and the data required to govern their health systems”. 

They should not “merely endorse externally financed programmes”, warns the report.

Within a year, countries should develop National Health Plans (NHPs) that include multi-year health investment plans, and map domestic and external resources, financing gaps, and “a realistic financing pathway”.

“Domestic resources become the foundation for core national responsibilities, while external financing is redirected towards managed transitions, capacity development, fragile settings, regional functions, emergencies and global public goods,” the report stresses. 

In the medium-term, NHPs can start to take on the functions of international organisations over a five- to 10-year period, managed by a country-led process with international partner buy-in. 

In cases where the global health institution will close, the report calls for “an orderly, time-bound wind-down with clear dates, sequencing, and the destination of all functions is agreed on up front within a foreseeable horizon of five to 10 years”.

However, it notes that “global entities in charge of normative guidance such as the World Health Organization (WHO) and those providing global public goods and humanitarian support need to continue.

The report was developed by the Reset’s 23-member High-Level Panel on the Reform of the Global Health Architecture and Governance.

This is co-chaired by Indonesia’s Health Minister Budi Gunadi Sadikin, Kofi Annan Foundation’s Dr Elhadj As Sy, Dr Peter Piot of the London School of Hygiene & Tropical Medicine, and Dr Priscila Ferraz, from Brazil’s Fundação Oswaldo Cruz (Fiocruz).

Image Credits: Presidency of Ghana.