GFO Issue 464, Article Number: 1
ABSTRACT
In this new issue of GFO, we examine the urgent need to rebuild global health governance in the face of deepening crises, including the abrupt PEPFAR withdrawal and funding instability. It highlights the critical role of community leadership, calls for structural equity in global decision-making, and showcases Botswana’s milestone in eliminating mother-to-child HIV transmission as a model of what inclusive, locally anchored responses can achieve.
Dear subscribers,
With every cycle of crisis, global health reinvents itself. But rarely has that reinvention been as urgent, as perilous, and as political as what is now required. The abrupt withdrawal of PEPFAR – a historic pillar of the HIV response – threatens not only to unravel two decades of progress, but to fracture an already fragile architecture, weakened by systemic inequality, overdependence on external financing, and deep power imbalances.
The 2025 UNAIDS report, both clear-eyed and alarming, outlines a dual reality. On the one hand, progress is undeniable: new infection rates are falling, access to treatment has expanded, and some countries are now approaching control thresholds once thought unimaginable. On the other hand, the threat is stark: without predictable, equitable, and sustainable funding, these victories risk becoming mere parentheses. The U.S. decision to disengage from PEPFAR, if confirmed and expanded, could unravel supply chains, interrupt treatment, and rekindle hotspots of infection long kept in check. This is not simply a budget shortfall – it is a political, moral, and strategic rupture.
In this context, the WHO must play a vital re-centering role. Not by trying to do everything, but by focusing on its core mandates: coordination, alerting, and support. Reinvention, in this case, is less a matter of technocratic reform than one of political rebirth. Diversifying funding sources, strengthening governance, and reclaiming a clear voice on priority mandates are not institutional niceties – they are collective survival strategies. Without a strong nucleus, the system fragments. And in a world where outbreaks move as fast as markets, a weakened WHO means a vulnerable humanity.
This is where community voices, so often dismissed, reclaim their centrality. The webinar held on 21 May by African civil society, in the wake of the Pandemic Agreement's adoption, resounded like a call to consciousness. These actors, rooted in communities, are far more than implementers – they are sentinels, bridges, and trust-builders where the state is absent or faltering. Without their full inclusion in planning, financing, and emergency responses, any global health architecture remains structurally unsound. The moral infrastructure of global health cannot be outsourced.
The call for equity goes further. It also touches the seats of power. Global health governance remains dominated by high-income countries, which hold 75% of leadership seats. The Global Fund’s Ethics and Governance Committee (EGC) is an important safeguard, yet it too faces challenges, such as language barriers. The contributions of African figures like Dr. Magda Robalo are crucial, but this is not about personalities – it is about building institutions where language, experience, and knowledge from the Global South are not peripheral but foundational. Equity cannot be cosmetic – it must be structural.
The report presented to the Global Fund Strategy Committee on community engagement in the grant lifecycle echoes the same truth. Community participation is too often a box-ticking exercise. For it to be meaningful, it must be structured, funded, and protected. Otherwise, it becomes empty rhetoric. And it is precisely this sustained, embedded engagement that distinguishes a merely technical response from a truly human one.
Botswana offers a powerful illustration of what can be achieved when political will, strategic health interventions, and community mobilization align. On 20 May 2025, Botswana became the first high-prevalence HIV country to achieve WHO’s gold tier certification for eliminating mother-to-child transmission of HIV. With a transmission rate now below 1%, this success is not a miracle – it is the result of years of testing, early treatment, governmental resolve, and community action. It is also living proof that global targets are within reach – when they are locally owned and implemented.
What this turbulent moment reveals is a deep fault line between two visions of global health. One, top-down and concentrated, still shaped by inherited aid hierarchies. The other, bottom-up and plural, rooted in local transformations. The challenge is no longer to do better within the old model – it is to do differently. To shift the center of gravity in global health, not toward another summit, but toward a new horizontal balance.
The current crisis – financial, ethical, and structural – is not a fatality. It is an opportunity for renewal. But only if we stop seeing communities as beneficiaries and recognize them as co-architects. Only if we stop equating presence in meetings with decision-making power. Only if we acknowledge that global health is not simply a matter of funding – but of equity, justice, and shared vision.
And any thoughts about which aspect in the global health initiative sector you’d like to see covered in our newsletter are always welcome and we’d really appreciate suggestions on who can pen an article on it! Anyone who wishes to voluntarily contribute as a guest columnist and provide an incisive analysis or first-person account of what is happening at micro – or macro – levels in the field of global health interventions is also welcome. Any feedback and suggestions in French, Spanish, English can be sent to Ida Hakizinka ida.hakizinka@aidspan.org and/or christian.djoko@aidspan.org
If you like what you read, do spread the word around and ask others to subscribe!
Dear subscribers,
With every cycle of crisis, global health reinvents itself. But rarely has that reinvention been as urgent, as perilous, and as political as what is now required. The abrupt withdrawal of PEPFAR – a historic pillar of the HIV response – threatens not only to unravel two decades of progress, but to fracture an already fragile architecture, weakened by systemic inequality, overdependence on external financing, and deep power imbalances.
The 2025 UNAIDS report, both clear-eyed and alarming, outlines a dual reality. On the one hand, progress is undeniable: new infection rates are falling, access to treatment has expanded, and some countries are now approaching control thresholds once thought unimaginable. On the other hand, the threat is stark: without predictable, equitable, and sustainable funding, these victories risk becoming mere parentheses. The U.S. decision to disengage from PEPFAR, if confirmed and expanded, could unravel supply chains, interrupt treatment, and rekindle hotspots of infection long kept in check. This is not simply a budget shortfall – it is a political, moral, and strategic rupture.
In this context, the WHO must play a vital re-centering role. Not by trying to do everything, but by focusing on its core mandates: coordination, alerting, and support. Reinvention, in this case, is less a matter of technocratic reform than one of political rebirth. Diversifying funding sources, strengthening governance, and reclaiming a clear voice on priority mandates are not institutional niceties – they are collective survival strategies. Without a strong nucleus, the system fragments. And in a world where outbreaks move as fast as markets, a weakened WHO means a vulnerable humanity.
This is where community voices, so often dismissed, reclaim their centrality. The webinar held on 21 May by African civil society, in the wake of the Pandemic Agreement's adoption, resounded like a call to consciousness. These actors, rooted in communities, are far more than implementers – they are sentinels, bridges, and trust-builders where the state is absent or faltering. Without their full inclusion in planning, financing, and emergency responses, any global health architecture remains structurally unsound. The moral infrastructure of global health cannot be outsourced.
The call for equity goes further. It also touches the seats of power. Global health governance remains dominated by high-income countries, which hold 75% of leadership seats. The Global Fund’s Ethics and Governance Committee (EGC) is an important safeguard, yet it too faces challenges, such as language barriers. The contributions of African figures like Dr. Magda Robalo are crucial, but this is not about personalities – it is about building institutions where language, experience, and knowledge from the Global South are not peripheral but foundational. Equity cannot be cosmetic – it must be structural.
The report presented to the Global Fund Strategy Committee on community engagement in the grant lifecycle echoes the same truth. Community participation is too often a box-ticking exercise. For it to be meaningful, it must be structured, funded, and protected. Otherwise, it becomes empty rhetoric. And it is precisely this sustained, embedded engagement that distinguishes a merely technical response from a truly human one.
Botswana offers a powerful illustration of what can be achieved when political will, strategic health interventions, and community mobilization align. On 20 May 2025, Botswana became the first high-prevalence HIV country to achieve WHO’s gold tier certification for eliminating mother-to-child transmission of HIV. With a transmission rate now below 1%, this success is not a miracle – it is the result of years of testing, early treatment, governmental resolve, and community action. It is also living proof that global targets are within reach – when they are locally owned and implemented.
What this turbulent moment reveals is a deep fault line between two visions of global health. One, top-down and concentrated, still shaped by inherited aid hierarchies. The other, bottom-up and plural, rooted in local transformations. The challenge is no longer to do better within the old model – it is to do differently. To shift the center of gravity in global health, not toward another summit, but toward a new horizontal balance.
The current crisis – financial, ethical, and structural – is not a fatality. It is an opportunity for renewal. But only if we stop seeing communities as beneficiaries and recognize them as co-architects. Only if we stop equating presence in meetings with decision-making power. Only if we acknowledge that global health is not simply a matter of funding – but of equity, justice, and shared vision.
And any thoughts about which aspect in the global health initiative sector you’d like to see covered in our newsletter are always welcome and we’d really appreciate suggestions on who can pen an article on it! Anyone who wishes to voluntarily contribute as a guest columnist and provide an incisive analysis or first-person account of what is happening at micro – or macro – levels in the field of global health interventions is also welcome. Any feedback and suggestions in French, Spanish, English can be sent to Ida Hakizinka ida.hakizinka@aidspan.org and/or christian.djoko@aidspan.org
If you like what you read, do spread the word around and ask others to subscribe!
