A changing global landscape

As the 54th Board Meeting of the Global Fund concludes, the uniqueness of The Global Fund (TGF) through 23-year-old partnership institution appears to stand at a crossroads. Reductions in international aid, the Global Fund largest donor’s changed approach to international aid, evolving approaches by other major donors toward global health financing, and broader geopolitical pressures are compelling the institution to rethink its path forward.

The Global Fund was born in a moment of urgency and solidarity. Today, it must adapt to a context defined by tighter fiscal space, climate change and shifting political priorities.

Mixed reaction to replenishment: generous or insufficient

The rolling 8^th replenishment mobilized US$11.9 billion - a substantial amount in the current financial climate, even if it falls short of the US$18 billion requested in the investment case could be considered a successful outcome.

Reactions have been mixed. Civil Society Organizations and few others argued that the amount is insufficient to protect gains of over 70 million lives saved through the Global Fund partnership to date and specific: more than 25 million people on antiretroviral therapy for HIV in 2024; 7.4 million people treated for tuberculosis in 2024; and 162 million insecticide-treated mosquito nets distributed to fight malaria in 2024. The Secretariat and donors emphasize that it represents a strong commitment, given global economic pressures. Implementer governments, especially Africans, are confronting a practical question: how can countries deliver the same impact with fewer external resources amid tighter fiscal space?

The debate is no longer simply about volume, but about efficiency and prioritization of the funds towards population health outcomes.

Transition as a strategic shift amongst other propositions

One of the Global Fund’s key shifts is transition. Upper-middle-income and some lower-middle-income countries (UMIC and LMIC), particularly those with lower disease burdens or increased fiscal Country Economic Capacity (CEC), are expected to gradually transition away from reliance on Global Fund financing.

A few more than 50 HIV, TB, or malaria disease programs are projected to transition out of Global Fund support by the end of the GC8 (end of 2029), with more transitions expected by the end of GC9 (2032) and subsequent cycles. This reflects a broader push toward sustainability and country ownership. However, readiness and the use of country system in the transition process require clear definitions.

Optimization and Market Shaping

Optimization has become a central theme. The Global Fund is calling for: rigorous programmatic prioritization, integrated service delivery, community systems and financing. increased and optimized domestic financing must be realised to sustain the transition. The Global Fund puts also a strong emphasis on NextGen market shaping

Market shaping has already demonstrated success with Antiretroviral Therapy (ART), once costing more than US$1,200 per person per year when the Global Fund was established, now averages approximately US$40. These price reductions have strengthened the argument that some countries are increasingly able to finance their own responses through taxes or and other innovative financing such as scale up multilateral financing for health through World Bank, IMF and regional development banks.

This gradual transition of UMIC and LMIC will allow the Global Fund and donors to focus their resources on the countries for which it is harder to fund the response: the low-income countries with significant burden or those affected by conflicts.

Integration and Sustainability

Integration is no longer optional. Disease-specific programs largely funded by donors are expected to move toward integrated service delivery within primary health care systems with more domestic investments.

Investments in data systems, supply chains, laboratory infrastructure, human resources for health, and pooled procurement mechanisms are essential to long-term sustainability. Community systems and financing must increasingly align with and strengthen national systems rather than operate in parallel. In addition, through social contracting, governments are expected to fund their civil society organisations. Strengthening the leadership of community organisations, aligning institutions on national plans, integrating platform and leadership will facilitate shaping the global health. The objective is progressive stability - ensuring that gains are maintained even as external financing declines.

Geopolitics and the Future of Multilateral Health Financing

The broader political context is unavoidable. Donor expenditure patterns are shifting toward defense and domestic priorities. There is reduced willingness in some quarters to finance other countries’ population health indefinitely. At the same time, geopolitical competition continues to reshape the global aid architecture.

However, this is not solely a story of contraction. Lower drug prices, stronger domestic capacity, and technological advances have changed the economics of disease control.

A moment of evolution

The crossroads facing the Global Fund is not a crisis of relevance but a moment of evolution. Transition, integration, sustainability, and optimization will shape its next chapter as GF evolves to pursue its core mandate of Saving Lives.

The coming years will determine whether the partnership can sustain impact in a more constrained and politically complex environment - and whether it can continue to deliver equitable, measurable results at scale. Clearly, as countries fund a larger proportion of their response and all stakeholders require prioritisation, the programs' coverage and delivery are likely to change.