BERLIN — Leaders of the world’s major global health institutions called for a fundamental restructuring of an aid system they described as too fragmented, duplicative and confusing, with several stating that the number of agencies must be reduced as cuts from the US and other donors force a reckoning with the labyrinthine architecture of global health funding.

At the World Health Summit in Berlin this week, executives from the Global Fund, Gavi, the World Health Organization and other institutions addressed the financial crisis facing global health as the abrupt withdrawal of US aid under Donald Trump exposed structural problems that officials acknowledged had existed for years.

“I do think we’re actually going to have to reduce the number of entities,” Peter Sands, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, told participants. “The system is too fragmented. There are too many underfunded institutions. There’s too much duplication. It’s too complex. That diagnosis, I think, is pretty straightforward.”

Global development assistance for health fell 21% between 2024 and 2025, driven almost entirely by a 67% drop in US financing, more than $9 billion, according to data from the Institute for Health Metrics and Evaluation.

Tens of millions of lives, particularly among children under five and people in the world’s poorest countries, are threatened by the cuts.

The collapse in global health funding extends beyond the United States. Germany, despite pledging €1 billion to the Global Fund and emerging as WHO’s largest donor, has cut its overall development assistance.

France and the UK, also major funders, have joined rich countries across the board in reducing aid budgets. EU member states face competing pressures from the war in Ukraine and heightened security concerns following recent Russian provocations inside and near NATO borders.

“On a global scale, development assistance for health was almost universally accepted as a good thing—it wasn’t politically controversial,” Joseph Dieleman, who leads IHME’s health aid tracking team, told the Council on Foreign Relations of the research. “All of a sudden, it’s very squarely political and on the chopping block.”

“That’s not just a US phenomenon,” Dieleman said. “That’s global.”

The loss of billions in health funding has put millions at risk, but officials say the crisis has also exposed deeper, long-standing flaws in the aid architecture. Health programs rely heavily on a handful of major donors — about 15 philanthropies and national governments dominate the field — so the loss of even one can trigger an immediate emergency.

“In the area of HIV, when the US paused their development assistance in February, in the whole global response on the HIV/AIDS, the US was shouldering 73% of the total burden of development assistance, just one country,” said Winnie Byanyima, executive director of UNAIDS.

“The rest of the world was shouldering the 27%. That wasn’t right,” she added. “That overdependence on one country, in a few countries, and overdependence of the developing countries, we have to solve it.” 

Officials also pointed to “mandate creep,” where multiple organizations take on overlapping roles, competing for the same funds while duplicating work, resulting in confusion and inefficient use of aid.

“At the moment, if you’re somebody from outside the world of global health, it’s pretty confusing, right?” Sands said. “And there are so many cross-currents and so many acronyms, and trying to explain where you should place your bets as a new donor is not a trivial thing to do.”

“The best answer for the Global Fund is you don’t need the Global Fund,” he added. “Ultimately, if we’ve done our job on HIV, TB and Malaria well, there’s no need for it. That’s not true for the normative convening, regulatory roles of WHO which will continue, ultimately indefinitely, because that’s playing a kind of global public good role for the world.”

The majority of global health institutions are funded through sequential “replenishment” fundraising campaigns, often concurrent, creating competition for finite resources that now extends across the broader humanitarian world. As funds dwindle, streamlining and coordination in aid efforts become crucial to maximise what funds remain.

“Is the current model of replenishment sustainable? I don’t think it’s sustainable going forward,” said Sania Nishtar, chief executive of Gavi, the Vaccine Alliance. “Whatever all of us have been able to achieve, it is because of the generosity of the donors … We do not have a divine right to funding.”

In 2024, the UN and partner organizations appealed for $46.4 billion to assist 180.5 million people across 72 countries—funding that health agencies must now compete for and convince policymakers to support.

“It is cliché, but a crisis is a chance,” Nishtar said. “Now is the time for us to come together and align behind a movement to draw new parameters.”

“We are radically recalibrating our programs. We understand that these changes are irreversible,” the Gavi chief concluded. “There’s got to be far less agencies in the ecosystem. This fragmentation and duplication really needs to come to an end.”

Without warning

The abrupt termination of US foreign aid, which has hit health programmes particularly hard, cast a long shadow over the chandeliers and canapés adorning World Health Summit proceedings at the Berlin InterContinental hotel, though participants largely avoided direct criticism of Washington.

Multiple panels on restructuring global health finance over the three-day conference avoided mentioning the US or President Donald Trump by name, instead speaking obliquely of the need for “innovative finance” and addressing funding gaps that now total tens of billions of dollars across major institutions including the WHO, Gavi and the Global Fund.

“The US has every right to use its money the way it wants. I don’t think anyone can criticize the US for withdrawing its funds or withdrawing its support,” WHO chief Dr Tedros Adhanom Ghebreyesus told participants via video-link from Sri-Lanka.

“But one thing that could have been done is there could have been a transition or an exit strategy, for instance, about six to 12 months,” Tedros added. “Then, countries who have been benefiting from the US generous support could have prepared themselves.”

Research published in The Lancet estimates USAID programs have saved over 90 million lives over the past two decades, including 30.4 million children under the age of five. As many as 14 million additional preventable deaths could take place by 2030 if gaps created by US programme cuts are not closed.

Later in the exchange, while acknowledging US sovereignty over its funding decisions, the WHO acknowledged that reality head-on.

“People have died,” Tedros said. “If there was some exit strategy, we wouldn’t have people dying because of the withdrawal of the US funding.”

“The abrupt US withdrawal will cost lives,” Axel Pries, president of the World Health Summit, said. “Estimations are that this is a double-digit million figure of lives which are lost due to this very abrupt change. On the other hand, it also exposed that our system had some kind of crackability already. It was not only this last push, it was already a system which needed a renewal.”

Already falling short

Even before the cuts, global health institutions were falling short of their targets, a pattern mirrored across humanitarian, refugee and climate financing.

The global fight against HIV, tuberculosis and malaria faces a $29.4 billion gap for 2027-2029 across domestic financing, external donors and the Global Fund combined. The Global Fund contributes roughly 13% of total global funding for these three diseases and has already warned countries that current grants for 2025-2026 might face an average 11% cut due to an estimated $1.4 billion gap from donors not meeting pledges.

“Global health has been very much anchored in global solidarity — countries agreeing to work together to deliver on health, and it’s been driven very much by aid for the developing countries,” Byanyima said. “But now we’re seeing that aid tumbling very fast — that suddenness, that rapid decline, is costing lives. Let’s be clear about that: people are dying.” 

Gavi secured more than $9 billion at its June replenishment summit but remains $2.9 billion short of its $11.9 billion target. Officials warned this shortfall could result in 75 million children missing routine vaccinations over the next five years and 1.2 million child deaths.

The Pandemic Fund—a multilateral mechanism established in 2022 by the G20—requires an estimated $2 billion in additional resources for 2025-2027. A further $15 billion in annual global spending on pandemic preparedness — or 0.1-0.2% of GDP and 0.5-1% of security and defence budgets — was recommended by a report from the WHO-hosted Global Pandemic Monitoring Board released in Berlin.

WHO faces the largest proportional crisis: it is short nearly $1.9 billion from a planned $4.2 billion budget for 2026-27, meaning it lacks nearly 45% of the needed funding.

Amid the funding drought, forcing many UN agencies from headquarters, to the UN Refugee Programme, to UNICEF and more to cut staff and operations by up to 55%, Sands warned that a simple restructuring will not solve the crisis alone.

“Rearranging the boxes of the global health ecosystem is a useful thing to do and a necessary thing to do,” he said. “But it isn’t going to fill the fundamental gaps in financing. So we should do it, but we shouldn’t use it as a sort of displacement activity for actually mobilizing the money we need.”

“The worst outcome here is that we invest a lot of our energies having long conversations and lots of meetings about all of this and then do nothing,” Sands concluded. “And two years from now, we’re not where you said we would be with a radically changed system. That would be a waste of time.”

Death and defence

Yet while aid budgets shrink, defense spending has been easier to find on government balance sheets, seeing a global surge last year from major aid donor nations as geopolitical tensions rattle capitals.

EU member states’ defense expenditure reached €343 billion in 2024, and is expected to rise to €381 billion in 2025—a 19% increase from the previous year and 37% higher than 2021. The US defense budget was approximately $874 billion in 2024.

“We face a world of national reflexes and shrinking budgets, of leading headlines and contested facts,” Nina Warken, Germany’s health minister, told the summit. “Global health politics is pressed to justify itself.”

“Health is no place for the lone wolf, because national health topics are often linked to the global level,” Warken added. “It is in our very own interest to strengthen these topics at an international level.”

The increases come as millions of preventable deaths occur worldwide from diseases that cost relatively little to treat or prevent. The $9 billion pricetag cost to fill the US-sized gap in global health funding, in perspective, is about 2.4 % of EU defence spending and about 0.66 % of the combined EU-US defence outlays.

“While we know we’re at a particular moment in time with financing for global solidarity now, the truth is funding pressures have long been there,” Helen Clark, former New Zealand prime minister and UN Development Programme administrator, said. “There is a competition for resources between the different sets of actors.”

The resources to allay the funding crisis are not confined to traditional Western aid budgets. Around 200 individuals with net worths exceeding $10 billion collectively hold approximately $5 trillion—enough to fund the current shortfall for over 500 years with money to spare. China’s annual government expenditure, estimated at $6-7 trillion, would absorb the $9 billion gap as roughly 0.13% of its budget.

Saudi Arabia’s Public Investment Fund, with assets estimated at $1 trillion, could sustain current global health funding levels for over a century. The kingdom’s recent investments in sports properties—including an estimated $10 billion across ventures such as LIV Golf, Newcastle United, and various international tournaments—exceed the immediate global health financing need.

Yet mobilising such resources remains a complex diplomatic and political challenge, further complicated by questions of how aid should be spent.

“In the final analysis, food, water, medicine to keep people alive is a compelling narrative,” Clark said. “That can absorb an overwhelming amount of resources that doesn’t really leave that much for putting in place the building blocks for more resilient health systems.”

African push for sovereignty clouded by debt

African leaders used the summit to accelerate demands for greater independence from donor systems. “Africa is ready. We don’t want to be invited,” Jean Kaseya, director-general of the Africa Centres for Disease Control and Prevention, told attendees. “We are the co-creators of this global architecture.”

“The money that we are creating, that we are leveraging, must flow through the regional pool procurement mechanism, especially to regional manufacturers, because we need an incentive to them,” Kaseya said. “Someone was telling me, there is no market in Africa. No way we have 1.4 billion people. This is the biggest market.”

In September, African health ministers released the Accra Agenda—a comprehensive financing strategy emphasizing domestic resources, innovative mechanisms and local manufacturing. The initiative, led by Ghana’s President John Dramani Mahama, aims to declare an end to development-as-usual.

Yet the push echoes the 2001 Abuja Declaration, in which African Union leaders pledged to allocate 15% of government budgets to health—a target only two countries of the AU’s 55 nations, South Africa and Cabo Verde, met in 2021. The average across the AU was 7.35% of national budgets, half the benchmark agreed in Nigeria 24 years ago.

“In the end, national actors are the ones who are going to carry their countries forward,” Clark said. “We have to put the emphasis on how we support them to do their jobs.”

Pressed on how the WHO would support countries affected by the global aid cuts, Tedros insisted they possessed the capacity for self-reliance. “All developing countries, what they need is not charity. What they need is fair terms, fair terms in investment, fair terms in trade, and fair terms in taking loans from the market,” he said.

Yet as the IMF and World Bank hold their annual meetings in Washington this week, the prospect of self-reliance appears increasingly remote for many developing nations.

Low-income countries, on average, depend on foreign aid for one-third of their national health spending. Eight of the world’s poorest countries—South Sudan, Somalia, Democratic Republic of Congo, Liberia, Afghanistan, Sudan, Uganda and Ethiopia—rely on USAID for over 20% of their total foreign assistance.

Facing their highest debt burdens in decades, many of the world’s poorest nations are unlikely to be able to compensate for the budget hole blown open by USAID’s withdrawal.

Research by Debt Justice, released ahead of the meetings, found that 11 lower-income countries denied debt relief by the IMF have been forced to enact “drastic” cuts to health spending by 18% and education by 16% while maintaining debt payments to wealthy creditors.

In these countries—including Argentina, Egypt, Kenya, Mozambique and Pakistan—real public spending per person has been cut by 10% on average, while GDP growth per person averaged just 1.2%, less than half the average for countries in the global South.

“The countries most dependent on development assistance are also the least capable of filling the gap,” Dieleman said. “The shift has been felt most acutely in low-income countries where disease burdens are high, particularly those in sub-Saharan Africa.”

The call for developing countries to increase domestic health spending confronts a debt crisis that makes such investments nearly impossible for many governments. More than 60 countries worldwide now spend more on debt service than on their health systems.

“The first thing we need to do is to organize a planned, a responsible transition from a model of aid,” Byanyima said. “We’ve seen the vulnerabilities of aid, and now we want to go away from that. But we must do it in an orderly way that’s not costing lives.”

Image Credits: World Health Summit, White House , Thinking Global Health, IHME.