The biggest change happening in global health today is not simply that funding is shrinking. It is that the architecture of global health cooperation is being quietly rewritten.
When discussions turn to global health funding, the focus is usually on the size of the cuts. How much has been reduced? Which programmes will close? How many people will be affected?
These are important questions. But they risk obscuring a more fundamental transformation. The real story is not simply that global health is losing resources. It is that the way those resources are governed, allocated and coordinated is changing.
A gradual shift away from multilateralism
For decades, global health has been built around a multilateral model. Countries pooled resources through international institutions, collectively agreed priorities, and relied on organisations such as the World Health Organization (WHO), Gavi and the Global Fund to coordinate action on shared health challenges.
That model has never been perfect. It has always reflected political negotiation, competing interests and unequal power dynamics. But it recognised one fundamental principle: some health challenges are too complex for any country to solve alone. That assumption now appears increasingly fragile.
What my research taught me about WHO
My doctoral research examined the governance and financing of the World Health Organization, focusing on one deceptively simple question: how does financing shape institutional independence?
Much of that research centred on the negotiations surrounding the Framework of Engagement with Non-State Actors (FENSA), adopted in 2016 after years of debate over WHO's relationships with philanthropic organisations, the private sector and other non-state actors.
Behind those negotiations was a broader concern that remains just as relevant today. As WHO became increasingly dependent on voluntary, earmarked contributions, questions emerged not only about where the money came from — but who ultimately influenced the organisation's priorities.
Nearly three-quarters of WHO's budget now comes from voluntary specified contributions.
Financing is never simply a technical issue. It is also about governance. Because whoever decides where resources flow inevitably shapes what institutions are able to do.
A different model is beginning to emerge
Recent political developments suggest that this debate extends far beyond WHO itself.
The United States' withdrawal from WHO, the freeze in USAID funding and the launch of a new US$4.5 billion global health funding platform under the America First Global Health Strategy are often discussed as separate policy decisions.
I see them differently. Together, they illustrate a broader shift away from multilateral financing towards increasingly bilateral and nationally defined approaches to global health cooperation.
The UK's recent reductions in overseas development assistance point in a similar direction.
Different governments. Different political contexts. Yet a remarkably similar trajectory.
Rather than strengthening shared institutions, funding is becoming increasingly fragmented across parallel initiatives shaped by national priorities.
Fragmentation is not a new problem, but it may become a bigger one
For years, fragmentation has been recognised as one of the greatest structural weaknesses in global health. Parallel funding mechanisms, disease-specific programmes and competing reporting requirements have often placed significant burdens on national health systems. One of the central purposes of multilateral institutions has been to reduce that fragmentation. To coordinate. To convene. To establish shared priorities. To provide legitimacy for collective action.
As financing shifts away from these institutions, an uncomfortable question begins to emerge: who performs that coordinating role?
The questions we should be asking
If financing increasingly follows national strategic interests rather than collective priorities — who decides which health challenges matter most?
If multilateral institutions become less influential — who coordinates international responses during the next global emergency?
If funding becomes increasingly selective — who supports the essential, but often invisible, investments in health systems, workforce development and preparedness that rarely attract political attention?
These questions are not theoretical. They sit at the centre of today's global health debate.
Beyond funding
It is tempting to describe recent developments simply as budget reductions. I think that misses the bigger picture. What we are witnessing is a gradual transformation in the architecture of global health governance itself. The institutions remain. The language of international cooperation remains. But the incentives, financing mechanisms and political logic that underpin them are beginning to change.
Whether this ultimately produces a stronger, more responsive system — or a more fragmented and unequal one — remains to be seen. What seems increasingly clear, however, is that the future of global health will not be determined solely by how much money is available. It will depend on who controls it, how it is governed, and whether collective action remains politically possible in an increasingly fragmented world.