Less than two years after the last comprehensive effort to reconsider parts of the global health architecture led to the widely endorsed Lusaka Agenda1, the global health community now faces a vastly different reality due to dramatic reductions in official development assistance for health. Three themes, not always connected, dominate discussions on how to respond.

First and dominant are frustrations from countries, particularly in Africa, around the behavior of development partners about ownership of global health efforts in their countries and affirmations of local health sovereignty, self-reliance, independence and leadership2. Second, although less prominent than one might have expected, are conversations on how to adapt to the severe funding cuts and mitigate their health consequences. Third, discussions on reforming the global health architecture, including the global health financing architecture.

Common to all these themes is the question of what the global health system should look like now and in the 2030s, after the current Sustainable Development Goal timeframe. What is the future of global health when global solidarity is declining, and post-World War II norms of international relations are fraying? Is regionalism the answer? Are self-sufficiency and ‘end of aid’ narratives helpful?

Several efforts are underway to resolve these queries. For example, the President of Ghana launched the SUSTAIN Initiative (Scaling Up Sovereign Transition and Institutional Networks) at the Africa Health Sovereignty Summit in August 2025. The Wellcome Trust has launched a series of regional dialogues on reforming the future global health architecture. For these efforts to be more successful than past efforts, it is important to sketch out the dimensions of the problem and take a systems approach to consider what the global health system should deliver in its entirety — even as individual countries and global health institutions focus on their own challenges and reforms.

Here we propose key questions for these efforts (Box 1) and aim to provide guidance on how to answer these questions. We present a framework for the different functions and contexts of the global health system, consider challenges for the operating models through which global health operates, and identify key cross-cutting issues.

The functions and contexts of the global health system

In Fig. 1, we present a non-exhaustive set of functions and contexts for the global health system, building on previous frameworks3,4. The functions are presented in a continuum for collaboration, starting with substitution in delivery (where external actors fund, contract and oversee execution in countries of key functions such as health service delivery, strategy and policy development, and data monitoring), which represents the lowest level of country ownership and leadership.

Fig. 1
figure 1

Functions and contexts for global health.

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We identify four broad contexts to apply these functions: humanitarian settings; stable low-income and lower-middle income countries (LLMICs; conflict-free with a state able to exercise authority over the whole country); upper middle-income countries (UMICs) and high-income countries (HICs); and the global, trans- and international setting. Across these contexts, marginalized population groups within countries must not be forgotten. Below, we use this framework to question what functions are still relevant for global health and which should be emphasized in each context.

Substitution for, or even crowding out, country functions, with limited engagement with and oversight by the state, must be avoided. One of the partial contributions of global health over recent decades is substantial increases in public health capacity in LLMICs. However, the current global health financing crisis reveals how much de facto substitution has been occurring in contexts where it should not. Stop orders decided in a donor country one day translate to health workers not going to work and patients not receiving life-saving treatments the next5.

Yet, there is still a plausible need for substitution in humanitarian settings (such as war and conflict zones), and more arguably in the lowest resource and capacity contexts, where the state does not have effective jurisdiction nor capacity to deliver, and where people experience the worst health. Substitution is also relevant for marginalized populations explicitly or implicitly excluded from the systems overseen by national and subnational governments. And yet, even where substitution might be justified, it should be seen as a temporary mode rather than a permanent commitment, with active efforts to revert to local ownership and delivery by the state as soon as possible. Substitution in stable LLMICs is not warranted or sustainable, and the current crisis is an opportunity to resolve this.

Financing support and direct technical assistance to countries will likely have a smaller role in this new era with substantially lower levels of health aid. Most financial resources for health in most countries are already mobilized domestically, and this will need to be expanded6. Technical assistance will be disrupted by the smaller footprint of aid ecosystems from vendors in HICs and of multilateral agencies who provide such assistance. But financing and technical support will remain important for humanitarian settings and for most low-income and many lower-middle income countries.

There is a strong case to sustain technical assistance even when major financing support has ceased in these settings. However, there are important questions about how grants and concessional loan channels can be aligned to country budgets and who and how to deliver technical assistance that genuinely and sustainably strengthens health systems at country level. The value and efficiency of technical assistance, the drive for ‘localization’ of such assistance to be delivered through national and local institutions, and the potential greater value of ‘South–South’ technical exchange need more reflection.

Global (or regional) public goods have been championed as the most important function of the global health system4,7, even if in practice and funding they have been eclipsed by financing support and technical assistance to countries. Global public goods can be differentiated between goods to be directly applied by and within countries — such as research, knowledge sharing, guidance, norms, standards, data and monitoring, market shaping and procurement — and goods for international collaboration to address transnational threats such as surveillance of infectious diseases, infectious disease control efforts and international legal instruments.

These supranational public goods must meet the demands of countries and provide added value, especially in an era of artificial intelligence where knowledge does not solely spring from a single authoritative source. Important discussions are needed on how to generate these global public goods through collective action, collaborative processes and fair contributions (avoiding ‘free riders’), and to clarify the role of regional versus global institutions.

Underpinning all these functions are the convening and stewardship processes of global health to support exchange between actors and countries, collaboration and decision-making, occurring at different levels of governance and supported by an array of organizations. The geopolitical changes that continue to unfold rapidly question what stewardship of global health, and its processes, should look like after 2030.

The operating model of the global health system

Global health actors have not always explicitly identified the need to operate differently according to setting and context but with reduced resources these choices are unavoidable. Although the most consequential work of recent decades has occurred within countries, the most visible setting for global health has, perhaps unsurprisingly, been the global level — and its universe of meetings and structures which have focused on ideas, agenda-setting, declarations and spawning new global initiatives, but whose impact is now questioned by country and regional actors and for which funding will be reduced.

The current funding cuts challenge the operating models of the global health system more fundamentally than ever before. How should global health actors be arranged at the country level to avoid duplication of work? The system has not undergone significant change for a quarter-century with a golden age now ending, with many of its institutions defined in the post-World War II period. There is an opportunity to reduce the competition, patronage building and transaction costs of multiple agencies operating independently at country level.

There has been a resurgence of interest in regionalism with new regional institutions gaining visibility and strength, while at the same time questioning of duplication between several organizations operating at global and regional levels. The current financing crisis is an opportunity to ask questions, understand past inertia and obstacles, and enact reforms towards greater effectiveness and efficiency that have always seemed impossible in the past8.

For example, how should financial and technical support for countries that still require substitution be prioritized? Should global health only provide such support for humanitarian settings? For low-income countries? With reduced levels of funding, when and how should transitioning out of financial support happen for lower-middle income countries as GDP per capita increases?

Prioritization is also required for UMICs and HICs, along with large lower-middle income countries with substantial economies. If the global health system can no longer afford country-based support in these contexts, can it still facilitate health equity and reach the poorest in these large countries with their large within-country health inequities? Indeed, there are calls from these countries that global public goods are the most useful function of the global health system, but that these goods need to be high quality and provide inputs that these countries do not already have9.

Cross-cutting issues

There are also specific cross-cutting issues. How will large vertical programs within countries (and global initiatives that fund them), such as HIV, tuberculosis and malaria programs, transition sustainably into the 2030s? Some have called for shutting down of these global funding streams10. However, it should not be assumed that the monies released will be reapportioned to some idealized global system; more likely such funding will disappear from global health, and hard-won achievements risk being erased. Leaders of these initiatives are putting forward reforms to their mandates, operations and structures aiming for more sustainable impact and alignment with the Lusaka Agenda11.

National governments retain the responsibility to protect and promote people’s health and wellbeing and ensure financing in line with maximum available resources12. Health ministries will need to effectively advocate for health as a national development priority. But it is unclear how all countries will finance these urgent gaps in externally supported vertical programs and also support their entire health systems in the face of cuts paired with increasing population expectations.

The catch cry in this crisis for increasing domestic health resources is not matched by country capacities given debt distress, weak tax collection systems, and poor confidence in governments’ ability to deliver. How can the global health and financial systems support measures such as solidarity taxes, debt relief, and reducing illicit financial flows? Without such mechanisms, countries will not be able to assume financing responsibilities. Yet given the current geopolitical fissures and crisis of solidarity, the prospects for these needed measures seem poor.

Finally, the most recent era of global health has seen substantive reductions in health inequities between countries, particularly for maternal and child health and infectious diseases, but inequities within countries have increased in many settings, exacerbated by the COVID-19 pandemic13. The global health system has been important for protecting the right to health within countries for populations who face structural discrimination, including by their own governments. In an era of reduced funding and influence of global health actors, how can these populations be supported to claim their rights and reverse the trend on health inequities, particularly when doing so requires multisectoral action, and key social determinants such as nutrition and education are also being affected by funding cuts?

Conclusion

The unrealized spirit of global agreements from Paris to Lusaka is of country needs and priorities leading and directing the global development agenda. In this global health financial crisis, many leaders in LLMICs have signaled their desire and political ambitions to become self-reliant and strategically independent14. At the same time, this is the moment for all countries to analyze and demand what they individually need from a reconceived global health system, and not just take whatever is offered or prescribed.

Many countries will need to build new capabilities and better draw on existing capacities to do so, as well as address health inequities and counter marginalization within their populations. Here, we have proposed a set of questions that countries and communities might address when developing a vision for a new global health era. Global health actors must support them in these tasks and might themselves consider the questions — but not aim to dominate the discussions or lead on the solutions.