Rethinking the Global Health Financing Architecture: Principles and a Proposed Model

Author: Gerald Manthalu

 

Introduction

The Lusaka Agenda has been gaining momentum, driven by interested stakeholders and accelerated by the recent cuts in foreign aid. Notable progress  includes: 1) the joint work of the Global Health Initiatives (GHIs) and pathfinder countries through the joint committee working group (JCWG) of Gavi, the Global Fund and the Global Financing Facility (GFF) and countries (Malawi, Mozambique, Guinea, Ethiopia and Chad) and similar work by the Africa Centres for Disease Control and Prevention (AfricaCDC) & the World Health Organization (WHO) AFRO with countries (Central African Republic, the Democratic Republic of Congo, Ethiopia, Ghana, Malawi, Mozambique, Senegal, and South Sudan) focussing on country specific reforms across the five strategic shifts of the Lusaka Agenda; 2)  country led aid alignment efforts such as  Sector Wide Approach (SWAp) approaches, One plan, One budget, and One monitoring and evaluation (M&E) mechanisms; alignment efforts led by Global Health Initiatives (GHIs) such as the Public Financial Management (PFM) work being championed by the Global Fund in selected countries and Gavi reform, the Gavi Leap, which aims to put countries at the centre, foster their self-reliance, and align with other GHIs [1]. 3) HIV/holistic service delivery sustainability planning supported by PEPFAR, UNAIDS and other donors. 4) Envisioning of Africa’s health sovereignty and the re-imagining of the global health governance architecture by African leaders at the Africa health sovereignty summit in Ghana on 5th August 2025 [2].

Rethinking the global health financing architecture, a key proposal of the Lusaka Agenda, has taken centre stage due to the recent sudden foreign aid cuts by the US Government [3]. A high-level panel of African leaders was established to develop a roadmap for a re-imagined global health governance architecture [4]. The European Commission has mandated a study on rethinking global health priorities and architecture in the context of the Lusaka Agenda. Wellcome has commissioned discussion papers and five regional dialogues from across the globe to explore and facilitate this conversation [5]. While a new health financing architecture is an imperative, its design must be guided by principles. This blog suggests seven such principles and gives their rationale. It also proposes an architecture based on the principles and steps towards realising it.

The principles

 1.           Effective government ownership

A new health financing architecture must place ownership of resources in the hands of governments. Currently, bilateral resources primarily reflect the interests of donor countries; as such, they are earmarked. Similarly, multilateral funding institutions earmark their support, though there are exceptions. This earmarking has led to the prescription of funding request processes, implementation arrangements (including predefining implementing partners, funds flow, and fiduciary oversight mechanisms) and monitoring and evaluation tools. These prescriptions have limited recipient countries’ priority-setting discretion, which, in my opinion, is the biggest flaw with foreign aid. Ensuring ownership of the resources by recipient countries will entail the following:

1.  Aid recipient countries must take increased responsibility for financing basic UHC packages from domestic resources.
2. Greater use of grant resources or a shift to predominantly concessional financing

These resources should be directed towards strengthening health systems to deliver the UHC package for an agreed transition period.

For these two actions to materialise, an incentive framework—agreed upon by donors and governments, and building on or going beyond current co-financing arrangements—will be required. In addition, strengthening health policy, governance, and institutional capacities in recipient countries will be essential.

The indebtedness of many countries may be a barrier to this proposal. Still, mitigation strategies could be agreed upon between donor and recipient countries for the specified transition period (for example, debt forgiveness, partial or complete, debt restructuring or debt buybacks).

 2.           Country-led priority setting

The increased ownership of resources by Governments of low- and middle-income countries (LMICs) must automatically facilitate country-led priority setting and the use of efficient service delivery approaches (safeguard mechanisms may be put in place where deviations from this expected behaviour are expected).  Decision making about and accountability for resources must be placed where responsibility for outcomes will occur and in the closest appropriate proximity to where the actions will be taken that will produce the outcomes [6].

 3.           Country-led accountability

Country-led accountability naturally derives from effective government ownership of resources. Only government-managed resources, delivered through country public finance management (PFM) systems, eliminate perverse incentives and have the capacity to de-verticalize implementation, thereby strengthening sector-wide accountability and performance management systems. Country-led accountability implies accountability to the citizens of the recipient country rather than to citizens of the donor countries or to the Boards of the funding entities. Accountability to citizens implies the devolution of resources to the sub-national level, reversing the current practice where accountability demands of donor resources constrain the devolution of resources.

 4.           Health maximisation

Health maximisation entails implementing health interventions that generate the highest health gain possible across all diseases/conditions subject to constraints of the health system; this approach will tackle the largest share of the burden of disease. It also implies assessing the opportunity costs of implementing interventions. Currently, vertical donor support prioritises interventions within the funded programme, even when such choices have a high opportunity cost in terms of foregone interventions in other programmes.

 5.           Service delivery integration

Building systems that support holistic health development for individuals and effectively respond to multimorbidity is crucial in the era of an epidemiological transition in low-income countries. The disease burden, particularly in sub-Saharan Africa and Malawi, is diverse and evolving, as illustrated in Figures 1 and 2 [7]. The top five causes of disease burden in these figures, for example, cannot be addressed by entrenching vertical systems. Vertical systems save lives from only specific diseases/conditions but seldom address a client’s holistic health care needs. Moving towards service delivery integration implies donors and recipient countries reaching a common understanding of success: donors that support vertical programs will report deaths or disability adjusted life years (DALYs) averted in a specific programmatic area to demonstrate success, but from the country point of view, progress in some areas, like HIV, may be more than offset by poor outcomes in others, such as non-communicable diseases or maternal and child health. Therefore, the new global health financing architecture must facilitate the building of integrated health systems that support patient-centred health care.

 

Figure 1: Burden of disease in Sub-Saharan Africa measured in Disability Adjusted Life Years (DALYs) for the year 2021

 

Source: Institute of Health Metrics and Evaluation, 2025

 

Figure 2: Burden of disease in Malawi measured in Disability Adjusted Life Years (DALYs) for the year 2021

 

Source: Institute of Health Metrics and Evaluation, 2025

  6.           Primary health care

Primary health care is a universally agreed approach to promote, prevent, treat and manage chronic conditions. It implies integrated, patient-centred health care delivery with community engagement and multisectoral collaboration. Fragmented, vertical, projectized, or non-public funding cannot build PHC systems. If PHC is at the centre of the rethink, it must be inevitable that PFM systems will be used.

 7.           Efficiency

The new financing architecture must maximise the proportion of the dollar that reaches the beneficiary. It must allocate the least amount of resources to the operations of global institutions that deliver aid, global intermediary health institutions, and administrative processes related to the development of grants in favour of direct country support. Leaner global institutions and streamlined processes, besides being efficient, will create greater room for country-led decision-making.  At the country level, the efficiency principle means that countries should adopt collective implementation approaches that yield the least cost per given output, without donor prescription. This requires governments to coordinate among Ministry of Health departments and other sectors. Countries should also decide which implementing partners they work with based on efficiency considerations.

 The proposed new architecture

 I propose a new global health financing architecture that builds on elements of the existing architecture that align with the above principles. It should have three functions as follows:

1.  Research and development (R&D)
2.  Market shaping and procurement
3.  Financial support to countries for holistic health development

For function number one, I propose that a framework be developed, say by regional health bodies (World Health Organisation/Centres for Disease Control) for aligning R&D with country needs and priorities, supporting technological transfer and enabling regional manufacturing. For function number two, I propose the creation of a new GHI with a sole focus on market shaping for a range of high-priority products, including medicines, medical supplies, and diagnostics, agreed upon through a bottom-up process. This function is currently in place at Gavi and the Global Fund; however, it is best to consolidate those roles within a new GHI that is neutral to disease and does not inherit the institutional legacies of the two existing institutions. For function number three, I suggest that the GFF and the World Bank be the sole entities that provide financial support to countries. Resources that are currently going to HIV, TB, and Malaria and immunisation should be consolidated under the GFF. I propose the GFF and World Bank model for the following reasons:

 1. The GFF and World Bank model meets most of the principles indicated above or is better suited to adjust to satisfy the suggested principles that it currently does not meet. 

• The GFF and World Bank promote country-led prioritisation and leadership, use relatively simple processes and utilise country public financial management and monitoring and evaluation systems [7]. 

2. The focus on women, girls, and children as opposed to disease areas facilitates:

• A holistic approach to addressing the health needs of these demographic groups
• Building health systems that cater for the needs of the whole population.

The focus could be adjusted with the proposed expanded role of the GFF so that other demographic groups, including the elderly, are equitably reached with cost-effective and feasible interventions. 

3. The GFF and World Bank combination is already complementary, as it combines GFF grant financing with the World Bank’s IDA support, which countries utilise for improving health and nutrition outcomes.

• The World Bank provides concessional financing to countries, mainly for health systems strengthening, which can augment health systems financing from existing GHIs.

4. The World Bank also houses the pandemic fund, which I propose should sunset and its functions be absorbed into an expanded GFF role. 

5. The World Bank and the GFF are financed by the same donors that finance existing GHIs, 

6. The World Bank has a presence in many countries.

I propose 2030 as the year when the new GHI for market shaping and procurement becomes effective and when the GFF consolidates resources from the other existing GHIs. 2030 is ideal because it is the endline for the Sustainable Development Goals (SDGs), and the Global Fund cycle eight finishes in 2029, laying the ground for a transition to a new global health order.

 Conclusion

The Lusaka Agenda has gained traction, as evidenced by numerous related initiatives at both global and country levels. A key Lusaka Agenda proposal has taken centre stage: the need to rethink the global health financing architecture. Such a process must be governed by principles. I have suggested seven principles: effective government ownership, country-led priority setting, country-led accountability, health maximisation, service delivery integration, primary health care and efficiency. I propose a new financing architecture that focuses on three functions: 1) Research and development, 2) Market shaping and procurement, and 3) Financial support to countries for holistic health development. For function number one, I propose developing a framework for aligning R&D with country needs and priorities, supporting technological transfer and enabling regional manufacturing. I propose creating a new GHI to discharge function number two, consolidating the functions that are currently in Gavi and the Global Fund and building on them. I propose that the GFF and World Bank should be the sole institutions for discharging function number three. The GFF will take over the country-financing roles that Gavi, the Global Fund, the Pandemic Fund, and other multilateral funds assume now. The GFF and World Bank model is proposed because it aligns with most of the proposed principles.

 

Acknowledgements

I appreciate the input of Dr Dominic Nkhoma and Dr Emilia Connolly. Any errors and inaccuracies in this blog are solely my responsibility.

 Author biography and conflict of interest statement

The author is a Director of Planning and Policy Coordination in the Ministry of Health in Malawi. In his official capacity, he has coordinated the development of funding requests for the Global Fund and Gavi (health systems components), Malawi investment cases under the GFF and project proposals to the World Bank. He is a GFF Government focal person and represents the GFF on the joint committee working group of Gavi, the Global Fund and the GFF, and, for the past year, he co-chaired the Friends of the Lusaka Agenda.

The author declares no conflict of interest; the views expressed in the blog are his personal views. They are not sponsored by, nor do they represent the views or the position of the Malawi Ministry of Health or of any of the institutions mentioned. 

References

1. Nishtar S: The Gavi Leap: radical transformation for a new global health architecture. The Lancet 2025, 405(10495):2112–2113.

2. https://futureofghis.org/friends-of-the-lusaka-agenda/

3. https://www.whitehouse.gov/presidential-actions/2025/01/reevaluating-and-realigning-united-states-foreign-aid/

4. https://presidency.gov.gh/statement-african-health-sovereignty-in-a-reimagined-global-health-governance-architecture-a-co%E2%80%91creation-summit-under-the-leadership-of-his-excellency-john-dramani-mahama-president-of-the/

5. https://wellcome.org/reports/bold-ideas-reformed-global-health-system

6. Wolf PJ: Authority: Delegation. In International Encyclopedia of the Social & Behavioral Sciences. Edited by Smelser NJ, Baltes PB. Oxford: Pergamon; 2001:972–978.

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