As we have tirelessly repeated like a cry from the heart in our recent publications, global health is going through a turbulent phase where three realities collide. In this complex landscape, historic alliances and technical instruments are no longer sufficient. They must be re-articulated around a simple yet demanding principle: what matters is not what we promise, but what we deliver – especially to those who need it most.

Let us begin with the strategic imperative of the moment: Gavi, the Global Fund, and the GFF must cooperate more deeply and effectively. Operational progress in malaria, health systems strengthening, and shared services proves that complementarity is not a slogan. It is visible in procurement channels, in shared data frameworks, in coordinated technical support. Yet blind spots remain: overlapping mandates, fragmented accountability, inequities in access. And with resources tightening, the method must change. Collaboration can no longer be rhetorical – it must become an architecture, built on shared goals, harmonized indicators, and clear divisions of responsibility. In short, a contract of results rather than a pact of intentions.

This budgetary realism is even sharper in the HIV response. PEPFAR remains the backbone of the global architecture, but 2025 has rattled that spine with a series of legal and budgetary shocks: authorization lapses, aid freezes, attempted rescissions. These jolts were not abstract. In Tanzania and Uganda, tangible disruptions appeared in ART continuity and prevention, especially for key populations. Yet in this unstable landscape, a window of opportunity opens: the at-cost rollout of twice-yearly long-acting PrEP with lenacapavir. It could reshape prevention – if and only if three conditions are met without delay: safeguarding the clinical backbone of programs, publishing timely data, and scaling up with rigorous pharmacovigilance. The next 6–12 months will be decisive. Outcomes will hinge on whether systems stabilize rather than remain in rolling uncertainty, whether last-mile supply chains are repaired, and whether coordination with the Global Fund can effectively secure service continuity.

On the financial front, the Global Fund is seeking to preserve the real value of pledges ahead of its Eighth Replenishment in November 2025. A new calculation method sets the exchange rate at the time of the pledge and permits corrections in case of major fluctuations. The objective is clear: cushion currency shocks, protect the purchasing power of contributions, and channel resources toward life-saving programs. This is not micro-accounting – it is public health applied to finance, ensuring that every dollar, euro, or yen translates into impact resilient to monetary turbulence.

That same discipline underpins the adjustments to Catalytic Investments (CIs) for Grant Cycle 7, presented at the 28th Strategy Committee meeting in Geneva on 7–8 July 2025. With a portfolio of US$555 million, CIs support strategic initiatives, regional efforts, and partnerships with the private sector. Cuts were applied with care: modest adjustments to priority interventions, corrections on a few multi-country grants based on performance, and protection of most Matching Funds – a critical lever for country ownership. Private sector contributions were preserved. In plain terms: trimming without breaking, prioritizing without sacrificing, keeping catalytic leverage intact where it delivers scale.

To govern such complexity requires safeguards and a compass. The strategic governance priorities for 2025–2028, discussed this month at the Ethics and Governance Committee (EGC), underscore that integrity is not a procedural luxury. It underpins donor confidence, program security, and institutional legitimacy. In this light, the Global Fund’s Additional Safeguard Policy (ASP), established in 2004, plays the role of last-resort risk management in politically unstable and institutionally weak contexts. Seventeen of the 29 ASP-listed countries are in Africa, some under this regime for more than 15 years. In 2024, the OIG pointed to poorly defined exit strategies, slow processes, and insufficient capacity-building. Current reforms are moving in the right direction: clearer exit criteria, stronger local systems, greater transparency. The challenge lies in balancing financial protection with national ownership. A safeguard regime without a credible exit path risks infantilizing systems; too hasty an exit risks costly breakdown. Reform must therefore combine thresholds, timelines, capacity benchmarks, and gradual off-ramps.

Across finance, programs, and governance, a common thread emerges: equity as the measure of rigor. Equity is visible in treatment continuity for key populations under crisis, in access to preventive innovations without social fractures, in the ability of national systems to absorb shocks, and in the quality of coordination among partners. Equity is not an afterthought – it is a condition of effectiveness. A dollar equitably targeted saves more lives than a dollar spent blindly.

The task now is to hold this edifice together. First, by codifying Gavi–Global Fund–GFF collaboration into genuinely integrated country portfolios: joint analyses of bottlenecks, synchronized calendars, shared performance and quality indicators, and collective accountability for results. Second, by protecting the HIV clinical backbone against PEPFAR instability: secure procurement, buffer stocks, continuity for community providers, and public dashboards tracking service delivery weekly. Finally, by making ASP transitions credible: co-negotiated transition pacts with verifiable milestones, conditional financing linked to systems strengthening, and capacity audits that reward progress rather than merely penalize gaps.

We no longer have the luxury of dispersion – or of slogans. The technical decisions of the coming months will have lasting political consequences. Taken wisely, they could finally align our financial instruments, governance structures, and field practices toward one shared end: measurable and equitable results. This is the standard by which our era will be judged – not by what we announce, but by what we deliver.

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
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