The high-level week of the UN General Assembly's 81st session ended in New York last week against a difficult backdrop for global health. Development assistance is falling, health systems remain under pressure, geopolitical divisions are deepening, and the institutions meant to coordinate collective action are being asked to do more with less.
Health was not the dominant issue of the General Debate: wars, security, climate change, artificial intelligence and the future of multilateralism took most of the political space. Yet across UNGA81's high-level meetings, health repeatedly surfaced as a measure of something larger: how international cooperation is financed, who sets global priorities, and how much authority multilateral institutions retain in a fragmenting system. Basically my current research agenda as I start as a visiting fellow at LSE.
For me, that is the most important story coming out of UNGA81: the financing problem is impossible to ignore as many of the commitments repeated in New York depend on financing that is now much less predictable.
The financing (reality) shock
Preliminary OECD data show that official development assistance fell by 23.1% in 2025, the largest annual contraction on record. The United States alone accounted for three-quarters of the decline. The OECD projects a further 6.9% fall in 2026, with health facing the deepest cuts: bilateral ODA for health and population services is projected to fall by 29–46% between 2024 and 2026. That would leave health aid below pre-pandemic levels. The cuts reach places where outbreaks are under way: health aid to the DRC and Uganda, both facing Ebola, is projected to fall by 46.6% and 53.5% respectively.
Speaking for the African Group at the High-Level Meeting on 25 September, Burundi called for financing for the Ebola response, citing needs of US$1.5 billion, alongside resources for preparedness, response and recovery. The Group also reaffirmed the Abuja target of at least 15% of national budgets for health, which few African countries have met, called for predictable, country-owned financing, and urged creditors to consider debt relief and debt-for-health swaps.
This is a significant shift in the conversation and in the way global health financing has traditionally been approached. For much of the past two decades, health financing debates in low- and middle-income countries have revolved around development assistance for health (DAH): how much external financing is available, where it is allocated, which programmes and institutions it supports, and how effectively it translates into health outcomes. In heavily aid-dependent countries it can be decisive. Malawi and South Sudan, for example, fund about 60% of current health expenditure from external sources.
The discussions at UNGA81 shifted the emphasis. Financing was discussed less as a question of mobilising more external resources, and more as a question of how countries can strengthen domestic financing, build institutional and productive capacity, and use international finance strategically.
This was most visible around Africa. At the Accra Reset's event in New York, the report A Sovereign Future for Health argued that domestic resources should be the foundation for core national responsibilities, with external financing redirected towards managed transitions, capacity development, regional functions, emergencies and global public goods. It also proposes that partners align behind one national health plan, one costed investment plan, the public budget and one country-led coordination platform. WHO Director-General Tedros Adhanom Ghebreyesus has made a similar case, describing the financing crisis as an opportunity to leave aid dependency behind.
The shift is towards understanding development assistance as part of a broader financing architecture, alongside domestic and regional capacity.
This does not make development assistance irrelevant. Where fiscal space is constrained, external financing remains essential, and the Accra Reset itself calls for managed transitions, not abrupt withdrawal. This is also where the growing emphasis on health sovereignty becomes significant. The concept is not new, and I have seen this first-hand in global surgery discussions around the implementation of National Surgical, Obstetric and Anaesthesia Plans (NSOAPs), where questions of financing, national ownership and capacity are closely intertwined. As external financing becomes less predictable, these questions become increasingly difficult to separate.
The Global South is asking for greater agency
One of the strongest themes across UNGA81 was the demand for greater agency from countries that have historically had less influence over global health priorities. It appeared in African discussions of health sovereignty. At a malaria side event, Zimbabwe and Angola highlighted plans for local manufacturing of nets and medicines, and Tanzania described local manufacturing as national policy. India told the pandemic meeting that preparedness should be rooted in national health systems and domestic financing, with international assistance complementing national responsibility. It was also visible in the BRICS agenda. The New Delhi Declaration endorsed the BRICS Integrated Early Warning System and a stronger network of national public health institutes, backed local and regional production, and reaffirmed WHO's coordinating role.
BRICS countries are not politically or economically homogeneous, and their positions should not be read as a single alternative model of global health governance. But their collective agenda increasingly emphasises regional cooperation, local production, regulatory capacity, surveillance and greater control over health technologies. It suggests that some Global South actors now understand resilience not only as access to international resources, but as the domestic and regional capacity to finance, produce, regulate and deliver essential health technologies and services.
The question becomes not simply how much aid should be provided, but what that financing enables countries to build. Does international finance reinforce long-term institutional and productive capacity? Does it strengthen national and regional systems? Does it allow countries greater control over their priorities? Or does it reproduce fragmented programmes and external dependence?
South–South cooperation is relevant here, and it is hardly new (it was the subject of my Master's thesis back in 2013). For more than two decades, governments and institutions across the Global South have developed forms of cooperation based on the exchange of technical expertise, knowledge, training, technology and, increasingly, financing. In global health, this has included everything from Brazil's technical cooperation and public-health diplomacy to India's pharmaceutical and vaccine production, and regional cooperation across Africa and Latin America.
For much of this period, South–South cooperation was often discussed as a complement to, or alternative source of, North–South development assistance. This does not make South–South cooperation a substitute for DAH. Nor does it mean that all South–South initiatives are inherently more sustainable, equitable or locally owned. They involve their own political interests, asymmetries of power and accountability questions. But they offer another way of thinking about what international cooperation can do: not simply transfer resources to fill financing gaps, but build capabilities that change countries' position within the global health system. UNGA81 offered a contemporary example: a side event on financing pandemic preparedness co-organised by Burundi and Guyana with PAHO and Africa CDC.
The growing emphasis on health sovereignty and the renewed attention to South–South cooperation are part of the same broader shift. Both raise questions about whether international cooperation can strengthen the capacity of countries and regions to define priorities, develop institutions, produce essential technologies and participate more equally in global decision-making. These are questions about the architecture of global health financing, not just its volume.
WHO remains central, but the system around it is changing
Having spent my PhD examining the World Health Organization, I cannot examine global health architecture without it. WHO remains the key multilateral institution for global health governance, and BRICS has reaffirmed its coordinating role. Yet it operates in a much harsher financial and political environment. The United States was not part of finalising the Pandemic Agreement, after moving to withdraw from WHO. At the 25 September meeting, Italy said it had not supported the Pandemic Agreement or the 2024 IHR amendments, arguing they expand WHO's role beyond its mandate. At UNGA81, WHO highlighted sustainable financing for health and for WHO itself, alongside pandemic preparedness, climate and health, digital technologies and health security.
The wider financing system is also fragmenting. Resources flow through bilateral donors, multilateral funds, development banks, philanthropies, private investors and a growing number of regional and country-led mechanisms. Fragmentation is not necessarily negative: new sources bring resources and flexibility, and regional institutions can lead where global ones cannot. But it creates a governance problem. Global health governance depends on coordination, priority-setting and accountability as well as money. When financing is spread across many actors, who ensures it collectively serves national priorities, and who is accountable when programmes compete? Who has the authority to coordinate action when no single institution controls the resources?
The Accra Reset answers with country-led platforms and a "functions before institutions" test, and its panel focused on five major institutions: Gavi, the Global Fund, the Global Financing Facility, the Pandemic Fund and Unitaid. That is a proposal to reform, and in some cases close, parts of the architecture.
A changing global health financing landscape
Taken together, the discussions in New York point towards a global health system undergoing a significant transition. External financing is becoming less predictable. Governments in the Global South are placing greater emphasis on domestic and regional capacity. African institutions are increasingly framing financing, manufacturing and institutional capacity as components of health sovereignty. BRICS countries are investing political capital in regional cooperation and alternative forms of South-South collaboration while continuing to support WHO. And multilateral institutions are being asked to coordinate a more diverse landscape with fewer resources.
This creates an opportunity and a risk. The opportunity is a financing architecture that strengthens domestic and regional capacity and gives countries more influence over the priorities that shape their health systems. The risk is that the decline of traditional assistance simply produces fragmentation, with resources divided among actors and programmes and no corresponding strengthening of coordination. The old architecture was built around a relatively clear distinction between providers and recipients. That line is blurring. Countries that were historically positioned primarily as recipients of development assistance are seeking greater influence over financing, production, technology and governance. At the same time, traditional donors are reducing or redirecting external assistance, while philanthropic, private and regional actors are becoming more prominent.
So the question I am left with is what kind of international financing a changing global health system needs. UNGA81 did not answer it. The answer will depend not only on how much money is mobilised, but on who controls it, what it builds, whose priorities it serves and how it is governed. That is ultimately a question of power, and one of the most important facing global health in the years ahead.