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Rupture, Not Transition: The Retreat of European Aid, the Human Cost of Global Health Cuts, and the Fight for a New System of International Cooperation

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Gonzalo Fanjul (1), Claudia García-Vaz (1), Madiha Shekhani (1), Laura Agúndez (1), Hugo Santa (2), Núria Botella (2), and Davide Rasella (2) *

Information about authors

 

1- Policy & Development department, Translation & Impact area, Barcelona Institute for Global Health (ISGlobal).

2- IMPACThealth: Global Health Impact Assessment and Evaluation Group, Barcelona Institute for Global Health (ISGlobal).

 

 

*All statistical and epidemiological analyses and results have been provided by IMPACThealth: The Global Health Impact Assessment and Evaluation Group, at ISGlobal.

*Published by ISGlobal with the valued support of Focus2030.

 

May 2026

 

Something fundamental is breaking in the international aid system. Over the past two years, France, Germany and the United Kingdom —three pillars of European development cooperation— have moved from incremental adjustment to structural retreat. This is not a cyclical correction. It is a redefinition of priorities with long-term consequences.

 

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Between 2023 and 2026, French aid will fall by roughly one third. Germany’s will drop by more than 36%, and the United Kingdom’s by 45% compared to recent peak levels. British ODA is set to reach 0.3% of GNI by 2027, its lowest level in a quarter of a century. Germany has reduced humanitarian assistance by nearly half at a time of record global displacement. France has redirected innovative solidarity taxes that once supported global health and climate initiatives back into the general treasury.

These figures are often presented as simple budgetary lines, but this ignores the way they are translated into lives. Using mortality models developed by ISGlobal’s IMPACThealth group, this paper estimates that the combined retreat of these three donors could result in more than 11.5 million additional preventable deaths by 2030 if recent funding levels are not restored. France’s cuts are associated with an estimated 3.5 million additional deaths over the decade. Germany’s trajectory could mean nearly 2.9 million. The United Kingdom’s reversal may cost more than 5 million lives that sustained investment might otherwise have saved. While these estimates are subject to significant methodological limitations, they remain indicative of the overall order of magnitude of this issue.

The sectoral implications are equally stark. Reduced funding for sexual and reproductive health risks over one million unintended pregnancies and hundreds of thousands of unsafe abortions. Lower contributions to multilateral institutions could leave millions of children without immunisation. Humanitarian reductions threaten food assistance for populations already facing acute fragility.

In the meantime, defence budgets across Europe are expanding rapidly. The political signal is clear: preventive instruments are shrinking while military expenditure accelerates. Yet development cooperation has long functioned as a stabilising tool —strengthening health systems, reducing fragility and mitigating the drivers of conflict and displacement. Weakening it may ultimately prove more costly than sustaining it.

This rupture also reveals the structural weaknesses of the previous model: excessive dependence on annual donor discretion, governance imbalances that limit ownership in the Global South, and fragile financing mechanisms. Simply restoring past funding levels would not be enough.

The alternative proposed in this paper rests on three fronts. Politically, health must be reaffirmed as a global public good, protected from transactional logic and supported by more legitimate and balanced governance. Scientifically, sustained investment in research, regional production and transferable technology platforms is essential to reduce structural dependence and respond faster to future crises. Financially, the system requires more predictable funding, innovative instruments and stronger coordination with national plans, alongside renewed commitment to quantitative targets.

The choice is not between generosity and austerity. It is between managing interdependence through cooperation —or allowing fragmentation to define the next generation of global health. 

1. The End of Development: Everything that Is at Stake

“This agreement no longer works. Let me be blunt. We are in the midst of a rupture, not a transition.” When the Canadian Prime Minister delivered those words at the Davos Economic Forum, he was talking about the geopolitical earthquake triggered by the second Trump administration and what he called the “era of great power rivalry.” However, Mark Carney could just as easily have been describing the not-so-slow-motion collapse of another pillar of the postwar order: the international development aid system, and the architecture of rules and institutions that sustains it. Like the commitments to free trade and the territorial integrity of states, the aid model has also been hit by a wave of unilateral decisions that are dismantling its budgetary, political and institutional foundations.

Of all the actors contributing to this catastrophe, the United States bears the heaviest responsibility. The dismantling of the United States Agency for International Development (USAID), sweeping budget cuts and the assault on the United Nations system have not only disrupted thousands of programmes in the world’s poorest regions, but put the survival of the entire multilateral architecture in question. Yet the United States is only part of the story. According to estimates by the Donor Tracker initiative,1 17 of the largest OECD donors will have cut their cumulative Official Development Assistance (ODA) budgets by nearly USD 43 billion between 2024 and 2026. Ten of the 17 countries analysed have already made or announced reductions; only Spain, Denmark and the EU institutions are planning modest increases in the immediate future.

Aid cuts come in painful contrast with the apparently unlimited rise in military and defence spending. According to a recent review by Devex, every NATO country is expected to raise its defense budget this year: “Germany’s total defense spending is expected to rise to about €82.7 billion [$98.23 billion] in 2026. This is about €29.4 billion [$35 billion] more than the amount earmarked in 2025. […] Italy has plans to boost its defense budget to €41 billion [$48.8 billion] from €29,7 billion [$35.4 billion], and the United Kingdom’s 2024 defense budget of €70,7 billion [$84.2 billion] is slated to rise to €76 billion [$90.5 billion]” .2

The dismantling of the United States Agency for International Development (USAID), sweeping budget cuts and the assault on the United Nations system have not only disrupted thousands of programmes in the world’s poorest regions, but put the survival of the entire multilateral architecture in question. Yet the United States is only part of the story.

The consequences of this tectonic shift in aid —which breaks an almost uninterrupted upward trend over the last quarter of a century— are measured in human lives. A recent study led by ISGlobal3 and published by The Lancet scientific journal provides an estimate of the impact of the cuts by analysing the relationship between funding flows and mortality rates in low- and middle-income countries for the past two decades. According to these calculations, a moderate cut in ODA budgets for global health programmes —maternal and child survival, HIV, malaria and health system strengthening, for example— would prevent the lives of 9.4 million people from being saved by 2030, most of them in Africa. In a scenario of deeper cuts, the figure could skyrocket to 22.6 million people, an amount equivalent to the combined populations of Norway, Austria and Switzerland.

The geopolitical consequences are already taking shape, in different directions. As traditional donors pull back, implementing countries are seizing the opportunity to advance their own strategies, a move that is long-due in a system flooded by the priorities of the Global North. But there is also an opening for non-traditional powers —led by China, followed by the Gulf states—, sometimes in ways that openly violate international law, as the UAE’s financing role in Sudan’s civil war illustrates. Among other implications, this power shift is likely to make it harder for European governments to build coalitions behind causes they care about, including Ukraine. Every unilateral reversal of an aid commitment is another blow to a credibility already weakened by Western double standards, as the massacre in Gaza dramatically showed.4

It would be naïve to think, though, that the aid system’s problems started in January 2025. Some of what the economic historian Adam Tooze has called ‘the end of development’5 speaks to failures embedded in the system long before the political earthquake of the last year. Aid bureaucracies have been criticised for decades —for their inefficiency, opacity, resistance to reform, and for their roots in colonial power asymmetries. The financing of global public goods has been far too reliant on the goodwill of individual donor governments and private philanthropists, at the expense of more structural and redistributive mechanisms like international taxation.

These criticisms are not new, nor are they necessarily related to the decisions made in recent months, but they hand ammunition to those dismantling it, such as the new US foreign policy mandarins.6 The most unsettling aspect of the current crisis may be how little resistance it has provoked. Public opinion in donor countries is witnessing the demolition of a decades-long effort —one that, for all its flaws, helped drive some of humanity’s most remarkable achievements, including the near-elimination of smallpox and a dramatic fall in child mortality— with something approaching indifference. Surveys on attitudes to aid, including one published by the Rockefeller Foundation in September 2025,7 show that support for development programmes remains broadly acceptable in most donor countries. Yet this support has no political teeth whatsoever. It is one thing for 61% of Americans or 49% of French citizens to say they back aid “even if it compromises some national interests”; quite another to take to the streets or change their vote over it.

The track record of aid —and its role in building a world shaped by shared rules and interests— is reason enough to oppose the current cuts and reject the “new normal.” But Carney’s other observation applies here too: “nostalgia is not a strategy”. Neither is a model of aid conceived as charity, or as a blunt instrument of geopolitical transaction. Even if we managed to reverse the decline in funding and shore up the international agencies, simply returning to the old architecture would be a mistake. The system had real weaknesses before it was attacked, and this moment of crisis is also an opportunity to rethink it —at the financial level, yes, but also in political and scientific terms, as the following sections set out.

This paper draws on three national case studies to map what is happening and why it matters: France, Germany, and the United Kingdom. By tracing the political and budgetary retreat of these three traditional donors, it estimates the resulting human cost in terms of preventable mortality and the strategic consequences for international security and stability. It then proposes an alternative set of global health and development policies, proving that there is a fertile third

2. The Trumpian Europe: The Retreat from Aid in France, the United Kingdom and Germany

The landscape of European development cooperation8 could be accurately described as a stampede. Led by its three largest donors, the continent is moving toward a "new normal" of significantly reduced international engagement —not as a temporary adjustment, but as a structural realignment of priorities.

For over a decade, France was a cornerstone of global health: the largest European donor to the Global Fund and a pioneer of innovative financing mechanisms. That momentum has now stalled. A combination of internal political backlash and mounting fiscal pressure has pushed development cooperation to the margins of budgetary debate, where it has become, in the words of government officials, an "easy target." With France's public debt nearly doubling the limit set by the EU, the 2026 budget implemented a cut of €803 million to ODA —making it the second most defunded line in the national budget.9

The damage, however, goes beyond the headline figures. France has de facto dismantled its innovative "solidarity taxes" on airline tickets and financial transactions —mechanisms that had raised over €700 million annually for health and climate multilateral initiatives— by redirecting those revenues to the general treasury. Alongside this, the quality of French aid has deteriorated: 19% of bilateral aid is now provided as loans rather than grants, heightening debt stress in countries like Senegal and Morocco. The 2021 development law had set a target of 0.7% of GNI by 2025; the government has since officially postponed that deadline to 2030.

The landscape of European development cooperation could be accurately described as a stampede. Led by its three largest donors, the continent is moving toward a "new normal" of significantly reduced international engagement —not as a temporary adjustment, but as a structural realignment of priorities

The German case tells a different story, though no less troubling. In 2025, following the United States' withdrawal from international aid commitments, Germany briefly became the world's largest ODA provider in absolute terms. That leadership proved circumstantial. Total ODA fell from 0.82% of GNI in 2023 to 0.67% in 2024, with projections forecasting a further decline to 0.43% by 2029.10 These levels have not been seen since 2014, effectively erasing a decade of progress.

The cuts have landed hardest on the most vulnerable sectors. The budget of the Federal Ministry for Economic Cooperation and Development (BMZ) is already 30% lower than in 2022.11 Humanitarian assistance was slashed by nearly 50% in 2025, reaching its lowest level in ten years at a moment of record global need.11 Germany also signalled a broader strategic retreat by reducing its pledge to the Global Fund for 2026–2028 by 23%.12

Of the three cases, the United Kingdom's retreat has been the most drastic —both politically and in budgetary terms. The erosion began with the 2020 dissolution of the independent Department for International Development (DFID), which brought aid down from 0.7% to 0.5% of GNI.13 In early 2025, the government went further ahead, announcing a reduction to 0.3% by 2027—a level ministers have explicitly described not as a temporary measure, but as the "new normal".14 This brings British aid to its lowest point in a quarter of a century, a triumph for long-time anti-ODA campaigners in the national-populist camp.

The structure of what remains is also cause for concern. The 2026 budget targets health spending with a 46% cut, and an increasing share of the remaining budget is consumed by In-Donor Refugee Costs (IDRC): by 2027, up to a third of the UK's bilateral aid may never leave the country, redirected instead to cover domestic asylum seeker costs.15

The human cost: Estimating the preventable loss of lives

The IMPACThealth group at ISGlobal has quantified the consequences of these withdrawals across more than 128 low- and middle-income countries (LMICs). Based on a prior study16 assessing the impact of USAID funding on mortality rates in LMICs, the estimated rate ratios for US aid were used as a pragmatic, though imperfect, proxy for estimating the potential impact of changes in France, the UK and Germany’s ODA funding on mortality. The results are stark.

The cumulative in French ODA between 2022 and 2026 is projected to result in more than 3.5 million deaths between 2023 and 2030 that could otherwise have been prevented —roughly 447,000 avoidable deaths each year. A specific 60% cut to France's Global Fund contribution alone could mean failing to prevent 710,000 deaths from AIDS, tuberculosis, and malaria by 2028.17

In Germany, the near-50% cut to humanitarian aid is projected to leave around 4 million people worldwide without food assistance.18 Assuming similar effectiveness of US and German aid, the 37% drop in ODA between 2023 and 2026 may result in ceasing to prevent almost 2.9 million deaths for the eight-year period between 2023 and 2030 —over 361,000 deaths each year. The ONE Campaign estimates that cumulative cuts of approximately €642 million to multilateral health institutions —including the Global Fund, Gavi, and UNFPA— are expected to contribute to over 650,000 preventable deaths by 2029 and leave 2.8 million children unvaccinated.19

The United Kingdom's retreat carries the largest individual impact on mortality in our analyses. Had the UK maintained its 0.7% of GNI for ODA commitment, an additional 5.1 million lives could have been saved between 2020 and 2030. Under the "new normal" of 0.3%, the capacity of British aid to save lives is nearly halved, ceasing to prevent more than 466,000 deaths each year. Sector-specific cuts compound this toll: a 30% reduction in sexual and reproductive health spending is estimated to result in 1.1 million unwanted pregnancies, 375,000 unsafe abortions, and over 1,000 additional maternal deaths

Table 1. Comparative human toll: The combined retreat of these three donors could result in over 11.5 million additional deaths by 2030 if funding levels are not restored.
Country Initial ODA budget Overall ODA drop and period Estimated ODA budget for 2026 Estimated deaths not averted by 2030 (total) Estimated deaths not averted by 2030 (per year)**
France USD 17.8 billion 30% drop (2023–2026) USD 12.4 billion 3,577,766 447,221
Germany USD 40.4 billion 37% drop (2023–2026) USD 25.4 billion 2,891,570 361,446
United Kingdom USD 21.5 billion 45% drop (2020–2026) USD 11.8 billion 5,131,147 466,468

* Limitations: These estimates assume similar effectiveness of US aid and that of studied countries, constant population structures and uniform in-country exposure to ODA. They act as a pragmatic proxy for the scale of mortality prevention lost during this period of rupture but shouldn’t be interpreted as causality. ODA budgets for 2026 (grant equivalent) as estimated by SEEK Development’s Donor Tracker, consulted on 27 February 2026. Averted deaths estimated using Total ODA gross flows. See individual case studies for a full explanation of the methodology used.

** Averted deaths change by year according to the specified reduction. For easier interpretability, the approximate number of averted deaths per year is reported here by dividing the total difference by the number of years.

The broader geopolitical consequences

The retreat of these donors is not merely a fiscal adjustment. It is a strategic shift —one that undermines European global influence and generates new security risks that will ultimately be costlier to manage than the aid they replace.

A common thread across all three cases is what might be called the "militarisation" of foreign policy: the systematic prioritisation of defence spending over preventive development instruments. In the UK, aid is being cut specifically to fund an increase in defence spending to 3% of GDP.22 In Germany, the development budget is set to fall by 11% while defence spending surges by 15%,23 financed by €180 billion in new debt.24 In France, while ODA faces an €803 million cut, defence and security spending is expected to increase by €6.5 billion by 2027.25 This reallocation ignores a well-documented reality: every dollar invested in conflict prevention can save up to $103 in future crisis response costs.26

The strategic vacuum created by this withdrawal is not remaining unfilled. As France retreats from the Sahel and the UK scales back its development footprint, China and Russia are expanding their influence through transactional strategies. The consequences are already visible in the difficulty France faces garnering African support for Ukraine while simultaneously deprioritising humanitarian crises on the African continent. The defunding of health systems, meanwhile, creates what analysts describe as "health security breaches," undermining collective capacity to respond to cross-border emergencies. And the cuts are accelerating forced displacement: following the 2025 aid reductions, an estimated 11.6 million displaced individuals risk losing access to direct humanitarian assistance.27

Against this backdrop, a counter-narrative of resilience is emerging. Spain has increasingly been cited as a strategic leader occupying the space vacated by retreating donors. Following the 2025 Financing for Development summit in Seville, the Spanish government has taken a proactive role in defending health as a global public good rather than a transactional instrument. Spain is amongst the few major donors planning modest aid increases for 2024–2026, alongside Denmark and EU institutions.

The European retreat also cannot be understood in isolation from a wider dynamic. These case studies contextualise it, in part, as a "contagion effect" initiated by the United States. Yet a key distinction remains: while the US executive has pursued a systemic dismantling of aid, Congress has at times acted as a stabilising force, cushioning the fall —a contrast to the UK, where parliamentary pushback has had little meaningful impact on the government's chosen course.

All in all, this strategic shift marks a historical crossroads. As the biggest donors move toward transactional aid and militarised budgets, the human cost is measured in millions of preventable deaths. The role of "normative leader" in international solidarity is increasingly left to others. What the current crisis demands is not a return to charity-based models, but the construction of a new system grounded in shared rules and mutual interests —a question the final section of this paper takes up directly.

3. The Road Ahead: The Political, Scientific, and Financial Foundations of a New Global Health Model

The evidence laid out in the previous section points to one conclusion above all else: aid works. This relatively modest mechanism for redistributing global wealth has underpinned some of the most consequential achievements of the past half-century. Nowhere is this clearer than in global health. The strengthening of health systems, mass vaccination programmes, and access to antiretroviral treatments represent a remarkable exercise in collective intelligence —and a concrete expression of what responsibility to others can look like.

The second conclusion is less comfortable: the system we have known is not coming back. The international cooperation architecture built after the Second World War is being contested both from within and without. The aggressiveness of major powers, combined with fiscal pressures and a political climate hostile to multilateralism, means that a transition to a different model is no longer a possibility to be managed —it is already underway. The question is not whether it will happen, rather what shape it will take and who will ultimately shape it.

The question is no longer whether there will be a transition, but who leads it and under what rules

Three possible futures present themselves. The first is the one already taking shape under the second Trump administration: a chaotic dismantling that has drained key global health priorities and redirected what remains towards narrow US economic and political interests. Congress has occasionally softened the blows, but it has not stopped the imposition of a transactional logic —one that turns development aid into a tool for leverage, coercion and extracting concessions. Normalising it among other traditional and non-traditional donors would fundamentally corrupt the purpose of aid.

The second future is a shrunken version of the status quo: the same actors, the same methods, and a fraction of the resources. This path would accelerate the system’s deterioration and force the international community to abandon even a scaled-down version of the commitments embodied in the 2030 Agenda.

The third option is more difficult to achieve, but more honest and certainly more meaningful in the longer term: a transition to a new system of international cooperation grounded in rules, rights and genuine shared interests. Not one that abandons ambition, but one that rethinks the roadmap —where the money comes from, who leads, and how accountability is enforced. In global health, this means addressing three fundamental fronts: political, scientific and financial. Alongside all three, runs a fourth challenge that is currently being lost: the battle for public narrative, as we will highlight in our final conclusions.

The political front: rules, legitimacy and coalitions

The future of global health cannot be built on nostalgia. The tools that enabled massive immunisation campaigns, the fight against HIV, and building health systems across the developing world were effective for their time, but the political and institutional conditions that made them possible are partially gone. The question is no longer whether there will be a transition, but who leads it and under what rules. Answering that entails a series of political challenges. The first one can be summarised in the most basic question: is health a global public good, or an instrument of external influence? When funding is made conditional on commercial or geostrategic interests, the result is fragmentation and competition at the expense of collective outcomes.

The second challenge is legitimacy. Global health governance still largely reflects the power dynamics of the late 20th century. The countries bearing the heaviest burden of health crises —and the bodies that represent them, such as the African CDC— still have limited say over the resources they are expected to implement. Without addressing this imbalance head-on, any appeal to a “rules-based system” will ring hollow in the Global South.

How do you build consensus in an era of bloc rivalry? Carney’s Davos argument for the stabilising role of “middle powers” —however much his speech overlooked the Global South— is relevant here. In the current environment, credible leadership may flow less from the size of a country’s chequebook than from its diplomatic capital, normative consistency and ability to build coalitions. In global health, Spain is emerging as one such actor —taking on a role as primus inter pares following the Financing for Development summit in Seville in July 2025.

How do we approach these challenges?

  • By reaffirming health as a global public good and protecting it from geopolitical and commercial exploitation. This involves decoupling health financing from short-term agendas of external influence and safeguarding essential commitments —vaccination, pandemic preparedness, health system strengthening—28 through stable multilateral frameworks.
  • By promoting a substantive WHO reform to strengthen its normative mandate, core funding, and coordination capacity. Over-reliance on conditional voluntary contributions limits its strategic autonomy. Increasing mandatory core funding and clarifying competencies would allow it to regain its central role as a technical and regulatory authority.
  • By building a coherent and balanced governance architecture, with greater decision-making weight for middle- and low-income countries and for regional bodies such as Africa CDC.29 The legitimacy of the system depends on those who implement policies having a real say in their design. Balancing representation and decision-making power is a political condition for the sustainability of the model.
  • By promoting the principle of “one plan, one budget, one monitoring framework” aligned with national priorities. The proliferation of vertical windows fragments systems and makes management more expensive. Alignment around integrated national plans improves efficiency, transparency and health sovereignty.
  • By encouraging the leadership of middle powers to sustain the multilateral system. In a context of rivalry between large blocs, countries with diplomatic muscle can act as stabilisers, using forums such as the G7 or G20 to keep global health on the agenda and build operational consensus.
  • By preserving and strengthening leadership in key institutions such as the Global Fund and Gavi. The withdrawal of funding from large donors can have a domino effect. Clear political leadership —accompanied by predictable contributions— reduces uncertainty and protects essential programmes.
  • By ensuring compliance with legal and parliamentary commitments on aid. Targets such as the UK's 0.7% of GNI for ODA or the French law of 2021 require binding timetables and accountability mechanisms to prevent their gradual erosion under pressure from fiscal deficits.
  • By promoting national processes of parliamentary reflection and public debate. Strengthening the democratic legitimacy of cooperation requires explaining its strategic and ethical value. Without public support, the system will remain vulnerable to short-term political cycles.

The scientific-technological front: knowledge, innovation and access

Science is not a luxury of wealthy nations —it is a prerequisite for reducing global structural inequalities. Any renewed model of development cooperation must have at its core a vision of research and innovation that serves the needs of low-income populations and the health systems they depend on.

The first element of the new agenda should be basic science and its normative and financial constraints. Decades of research into messenger RNA made it possible to develop effective COVID-19 vaccines in record time. But the pandemic also showed that generating knowledge is only the opening move, not for the first time in recent history. The story of antiretroviral treatments for HIV —whose price collapsed after the introduction of generics and sustained international pressure— is a reminder that intellectual property rules and financing mechanisms are as decisive as anything that happens in a laboratory. The same lesson applies today to antimicrobial resistance and tuberculosis, where commercial incentives remain structurally insufficient.

Applied technological development is the second pillar. Progress in South Asia and sub-Saharan Africa over recent decades has rested on adapted vaccine platforms, affordable rapid diagnostics, and simplified treatments that allow care to be delivered far from urban centres. The pandemic demonstrated, through mechanisms like CEPI (the Coalition for Epidemic Preparedness Innovations) and COVAX (the COVID-19 Vaccines Global Access initiative), just how fast the timeline from research to rollout can be compressed when there is a shared and urgent sense of risk.

The third pillar is what might be called “strategic sovereignty” —the capacity of affected regions not just to access innovations, but to produce and regulate them. Initiatives to manufacture vaccines in Africa, including the mRNA technology hubs established in South Africa, point in the right direction. The same logic drives efforts to build regional regulatory agencies and shared data systems across Africa and Latin America: the goal is to shorten the path from innovation to distribution, without depending on decisions made elsewhere.

Innovation in global health is not only about biomedical breakthroughs. Integrated primary care, community health programmes, and digital tools for epidemiological surveillance have shown health returns that rival those of any new drug.

Investment in science for global health is not a secondary priority —it is the foundation of any credible long-term strategy. The main measures this implies are:

  • Providing stable funding for research into neglected diseases and antimicrobial resistance. Purely commercial logic does not provide sufficient incentives in these areas. Public and multilateral mechanisms must share risks and make funding conditional on access and affordable pricing criteria.30
  • Consolidating transferable technology platforms. Investing in adaptable technologies —new-generation vaccines, rapid diagnostics, interoperable data systems— enables a rapid response to emerging threats without restarting the innovation cycle from scratch.31
  • Strengthening regional regulatory and production capacities. Local production of vaccines or active ingredients, together with robust regulatory agencies, reduces strategic dependence and improves response times to health crises.
  • Promoting co-investment and matching fund mechanisms to mobilise national resources. Counterpart models can incentivise partner governments to increase their investment in essential products, reinforcing fiscal sustainability and national ownership.32
  • Integrating biomedical innovation with organisational innovation. Improvements in primary care, community models and digital surveillance tools can generate health returns comparable to those of new pharmaceutical technologies.

The financial front: innovative mechanisms, diversification and accountability

The financial debate is not just about how much money is available, but where it comes from and on what terms. The cuts documented in this paper have exposed a structural vulnerability: the entire system rests on the annual budget decisions of a handful of governments, making it hostage to electoral cycles, fiscal pressures and political mood. The first priority must therefore be to diversify and stabilise sources of funding.33

Health as a global public good demands more predictable, less discretionary funding.34 The experience of innovative mechanisms like France’s airline ticket taxes —which once supported UNITAID before being redirected to the general treasury— shows it is possible to generate significant resources at relatively low political cost. The voluntary reallocation of Special Drawing Rights to health resilience funds, or a more strategic use of multilateral bank balance sheets, could similarly expand fiscal space without relying solely on traditional aid transfers. The Pandemic Fund has mobilised billions in financing for low- and middle-income countries through a collaborative model that combines donated and co-financed resources from countries, providing a current and operational example of catalytic financing. Its third round of proposals approved USD 500 million in grants and has mobilised more than USD 11 billion in total since 2023.35

This effort cannot fall only on traditional donors. Middle-income countries in the Global South will need to expand their fiscal capacity to absorb a growing share of their own health systems —and of regional cooperation mechanisms. The new financial contract cannot be a unidirectional flow of resources from North to South; it has to be a network of distributed responsibilities.

Volume is only half the problem; quality matters just as much. The expansion of blended finance and instruments designed to mobilise private capital has produced mixed results. In high-poverty, low-return environments, private capital does not replace public investment —at best, it complements it. For vaccines, pandemic preparedness and primary system strengthening, concessional public financing will remain irreplaceable.

A reformed ecosystem must also tackle institutional fragmentation. The proliferation of vertical funds and siloed financing channels drives up management costs and dilutes accountability. Simplifying the system, aligning vertical funds with national plans, and linking disbursements to measurable health outcomes rather than short-term geopolitical priorities would make the money go further —and be more defensible in the face of the public that ultimately funds it.

Concretely, this means:

  • Re-establishing and fulfilling quantitative aid commitments. The gradual return to the 0.7% of GNI for development target and the full implementation of legal commitments are signs of predictability. Financial stability is a prerequisite for multi-year health planning.
  • Protecting the global health budget from being replaced by domestic expenditures. Counting in-donor costs as aid erodes the capacity for international engagement and distorts strategic priorities.
  • Exploring innovative taxes earmarked for global health in donor countries. Instruments such as aviation or financial taxes generate additional resources with demonstrated public acceptability. Their clear allocation to health funds reinforces both fiscal transparency and budgetary predictability.
  • Expanding the use of IFFIm and other advanced financing instruments. Mobilising future resources allows for immediate investments in immunisation and system strengthening without relying exclusively on annual budgets.
  • Expanding debt-for-health swaps. Transforming external liabilities into national health investment improves fiscal sustainability and system resilience.36
  • Strengthening the strategic role of multilateral development banks. Their capacity for concessional financing and guarantees can catalyse structural investments —infrastructure, digitalisation, regional production— that exceed the scope of vertical funds.
  • Improving coordination between multilateral banks and global health actors. Reducing fragmentation and aligning technical and financial resources around integrated national plans improves efficiency and accountability.
  • Promoting domestic resource mobilisation in middle-income countries. The sustainability of the system requires progressive fiscal co-responsibility, accompanied by technical assistance and co-financing frameworks that facilitate the transition.37 Fiscal mechanisms such as health taxes —tax increases on tobacco, alcohol, and sugary drinks— have been proven to successfully generate steady public revenue that can be used to strengthen health systems even in low-income settings, as has been the case in Ethiopia.38

4. Conclusions

No one needs to explain to the millions of people who will lose access to vaccines, treatments, food assistance, or maternal care why this moment represents a rupture rather than a simple transition. For them, the distinction is not conceptual but existential. The findings summarised in this paper translate budget lines into human consequences measured in lives not saved, infections not prevented, and systems left unprepared. The scale of the projected losses should leave little room for semantic comfort: this is not an orderly recalibration of priorities; it is a structural break in a model that, for all its imperfections, has demonstrably worked.

The temptation will be either to normalise the cuts as inevitable or to attempt a cosmetic restoration of the previous architecture. Neither path is acceptable. The correct path is the difficult one: to acknowledge the political weaknesses of the old model, to correct its financial fragilities and governance imbalances, and to rebuild it on clearer foundations of shared rules and interests

The decisions made in the coming months will shape a framework that could prevail for a generation. The temptation will be either to normalise the cuts as inevitable or to attempt a cosmetic restoration of the previous architecture. Neither path is acceptable. The correct path is the difficult one: to acknowledge the political weaknesses of the old model, to correct its financial fragilities and governance imbalances, and to rebuild it on clearer foundations of shared rules and interests.

Some governments will play a decisive role in determining whether this reconstruction succeeds. In light of the big donors’ stampede, middle powers with diplomatic credibility, strategic vision, and a willingness to work across the geographical spectrum can help stabilise a fragmented system. Yet expectations must remain realistic. What recent months have shown is that the reactionary current led by the United States is no longer an anomaly but increasingly the norm —whether embraced out of conviction or tolerated out of political caution. Leadership from governments, while essential, will not be sufficient on its own.

If the system is to endure, it will require something far more ambitious: a public re-engagement with the idea of international cooperation as an imperfect but indispensable expression of solidarity and shared security. Surveys suggest that support for aid has not collapsed, but it has become politically inert. Reconnecting citizens to the tangible achievements of global health —its clarity of purpose, its measurable outcomes, its contribution to collective resilience— is not a secondary task. It is central to survival.

Aid is not charity. It is a flawed, contested, but reasonably effective mechanism for helping to manage interdependence in a connected world. Preserving and reforming it is not an act of generosity. It is an act of strategic responsibility toward future generations.

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5. References

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8. The data contained in this section is sourced in the three case studies that precede this paper.

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14. UK Parliament. Defence and Security: debate in House of Commons, 25 Feb 2025, vol 762. Hansard. Available from: https://hansard.parliament.uk/commons/2025-02-25/debates/8BF58F19-B32B-4716-A613-8D5738541A30/DefenceAndSecurity#contribución-DB32B970-42F2-4B1B-A92C-54CA0B28BA41

15. Independent Commission for Aid Impact. Management of the Official Development Assistance (ODA) Spending Target: Information Note. London: ICAI; Jul 15 2025. Available from: https://icai.independent.gov.uk/wp-content/uploads/Management-of-the-ODA-spending-target_ICAI-information-note_Jul-2025.pdf

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19. Deutsche Entwicklungszusammenarbeit: Die Kosten der Kürzungen. Berlin; 2025. Available from: https://data.one.org/analysis/die-kosten-der-kuerzungen

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25. Le Monde. Emmanuel Macron annonce 3,5 milliards d’euros de dépenses supplémentaires pour la défense en 2026 et 3 milliards d’euros en 2027. 2025 Jul 13. Available from: https://www.lemonde.fr/politique/article/2025/07/13/emmanuel-macron-annonce-3-5-milliards-d-euros-de-depenses-supplementaires-pour-la-defense-en-2026-et-3-milliards-d-euros-en-2027_6621049_823448.html

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28. Global Preparedness Monitoring Board (GPMB). The Changing Face of Pandemic Risk: 2024 GPMB Pandemic Risk Report. Geneva: World Health Organization; 2024. Available from: https://www.gpmb.org/reports/m/item/the-changing-face-of-pandemic-risk-2024-report

29. United Nations Population Fund (UNFPA) and Africa Centres for Disease Control and Prevention (Africa CDC). UNFPA and Africa CDC forge strategic partnership to advance health and innovation across Africa. 12 Feb 2026. Available from: https://esaro.unfpa.org/en/news/unfpa-and-africa-cdc-forge-strategic-partnership-advance-health-and-innovation-across-africa

30. Slovenski I, Alonso Ruiz A, Vieira M, Large KE, Strobeyko A, Liu Y, et al. Beyond resistance: alternative innovation models for global access and stewardship of new antibiotics. Humanities and Social Sciences Communications; 2025. Available from: https://www.nature.com/articles/s41599-025-06337-y

31. Such as the Access to COVID-19 Tools Accelerator (ACT-Accelerator). Available from: https://www.who.int/initiatives/act-accelerator

32. Kumraj G, Pathak S, Shah S, Majumder P, Jain J, Bhati D, et al. Capacity Building for Vaccine Manufacturing Across Developing Countries: The Way Forward. Hum Vaccin Immunother; 31 Dec 2022;18(1):2020529. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8986212/

33. Friends of the Global Fight, The ONE Campaign, RESULTS. Expanding Global Health Finance: Convening Report and Agenda for Action. Sep 2025. Available from: https://www.theglobalfight.org/wp-content/uploads/2025/09/25022FGF-Global-Health-Finance-Report-R5-DIGITAL-09152025.pdf

34. Institute for Health Metrics and Evaluation (IHME). Financing Global Health 2023: The Future of Health Financing in the Post-Pandemic Era. Seattle, WA: IHME; 2024. Available from: https://www.healthdata.org/sites/default/files/2024-05/FGH_2023_Accessible_Digital_Version_with_Translations_2024.05.13.pdf

35. Pandemic Fund Third Call for Proposals (Nov 2025). Available from: https://www.thepandemicfund.org/news/announcement/announcement-3rd-call-proposals

36. See, for instance, the experience of the Global Fund: https://www.theglobalfund.org/media/3k1gvfom/publication_debt2health_overview_en.pdf

37. Innovative Financing to Future-Proof Universal Health Coverage (Think Global Health, Sep 2025). Available from: https://www.thinkglobalhealth.org/article/innovative-financing-to-future-proof-global-health

38. World Health Organization. Ethiopia takes bold strides on health taxes to drive Universal Health Coverage. Brazzaville: WHO Regional Office for Africa; 2025 Jul16. Available from: https://www.afro.who.int/countries/ethiopia/news/ethiopia-takes-bold-strides-health-taxes-drive-universal-health-coverage