As the master of ceremonies asks the audience to “take your seats for the final moment of the day”, the scene is flawless. African fabrics, warm lighting, a spellbinding slam performance, four survivors sharing their stories of HIV, tuberculosis and malaria. The dramaturgy is impeccable: “We cannot stop now”, repeat both artists and leaders. Then comes the long-awaited figure: 11.34 billion US dollars pledged for the Global Fund’s next cycle. The room erupts in applause.

But behind the emotion, the arithmetic is unforgiving: the 18-billion target has not been met. For the second time in a row, the Global Fund leaves a replenishment conference with a massive shortfall – roughly one third of the goal missing. In the room, nobody says it quite that bluntly. Yet it is this number, more than the fabrics and the songs, that will shape the future of programmes in Africa and beyond.

Perfect staging, half-measure results

Johannesburg offered everything the official narrative likes: a G20 summit in Africa, North–South co-hosting (South Africa / United Kingdom), powerful testimonies, a unifying slogan “stop at nothing” and a very deliberate centring of communities as the heart of the response. The message is clear: the partnership works, solidarity is alive, and the Global Fund remains one of the great success stories of global health multilateralism.

The long-term numbers partially justify the celebration: the Fund estimates it has saved 70 million lives since 2002 and reduced the combined death rate from HIV, tuberculosis and malaria by nearly two-thirds in the countries where it invests. In 2024 alone, 25.6 million people received antiretroviral treatment, 7.4 million were treated for TB, and 162 million insecticide-treated bed nets were distributed. Few instruments can point to such a cost–impact ratio.

Private sector mobilisation so often invoked as the “new frontier” of global health also reached a record level: 1.34 billion US dollars pledged by companies and foundations for this eighth replenishment, the highest private support in the Fund’s history. This matters but it does not fill the hole left by shrinking public contributions.

Because that is the core problem: despite the staging of solidarity, the total plateaus at 11.34 billion US dollars for 2027–2029, far below the 18 billion judged necessary to stay on a trajectory compatible with global goals against the three diseases. Some major donors have reduced their commitments : the United States, the largest contributor, moves from 6 billion pledged at the 7th replenishment to 4.6 billion today; the United Kingdom announces 850 million pounds, down from the previous cycle. Others, such as France, Japan and the European Commission, simply did not announce a figure in Johannesburg, promising instead to come back “later” with a contribution.

On stage, at the scale of a single event, the moment is triumphant; at the scale of needs, it is a half-measure result and a potentially dangerous one.

A budget gap that reveals the crisis of health multilateralism

The easy reaction is to treat this shortfall as a one-off mishap, a by-product of a “difficult context”. That would be a mistake. This funding chasm is a symptom of a much deeper crisis in global health multilateralism and development assistance.

For several years, international aid has been falling in real terms, squeezed between domestic crises (inflation, cost-of-living, fiscal tightening) and political shifts (national interest first, rise of the right and far-right, anti-“woke” and anti-multilateral rhetoric). The speeches in Johannesburg bear the imprint: there is less talk of solidarity and more of “investment”, “economic returns”, “reform of the international financial architecture” and private sector mobilisation.

On the donor side, the implicit message is two-fold. On the one hand: “We continue to support the Global Fund because it is effective, because it protects our health security and because it creates opportunities for our private sector.” On the other: “The era of the old aid model is over; implementing countries must become more ‘self-reliant’, raise more domestic resources and accept faster transitions.” This is exactly the line now championed by the Fund’s leadership, which has announced a 20% cut in its own operating costs from 2026 and is already signalling possible reductions in grants through end-2026 because of funding pressure.

On paper, searching for efficiency is legitimate: trimming overheads, avoiding duplication with other mechanisms, aligning better with Gavi and the World Bank – all of this is reasonable. But when you try to “do more with less” at a time when needs are rising, the exercise quickly becomes “doing less with less”. And that “less” will translate very concretely into services shut down, treatment delayed, innovations postponed – all the more dramatic as we stand on the brink of major breakthroughs: long-acting HIV prevention, new generations of bed nets and malaria vaccines, shorter and more effective TB regimens.

The silence of several historic donors in Johannesburg is also political. France, Japan and the European Commission have all played structuring roles in the global health architecture of the past two decades. Their failure to put numbers on the table at the very moment the Global Fund is sounding the alarm sends an ambiguous signal: symbolic support to multilateralism, but clear reluctance to fund it at the level needed.

Moreover, according to an internal document revealed by Euractiv, the European Commission is considering ending its financial support to the Gavi Alliance and the Global Fund by 2030.

Finally, the shift towards a rhetoric of “accelerated transition” and “end of the aid model” carries a major risk: offloading onto high-burden countries; especially in Africa the adjustment for a choice that was first made in Northern capitals. In plain terms: we have collectively decided to put less money into fighting three pandemics that still kill nearly 2 million people every year – it is now up to you to absorb the shock.

Africa on the front line, but not in the cockpit

Symbolically, this eighth replenishment is a milestone: for the first time, the summit is co-chaired by an African and a Northern country, on African soil, within a G20 itself hosted for the first time on the continent. The fabrics, the songs, the testimonies of the “fabric champions” all underscore that the epidemics in question are lived first and foremost in African villages, townships and informal settlements.

South Africa announces a combined government–private sector pledge, converted into rands, and calls on domestic companies to “step up and be counted”. Other African countries have, in recent years, inscribed sometimes modestly a “Global Fund” line in their budgets. It would be simplistic to belittle these gestures: they reflect a genuine political will not to remain merely “recipients”.

Yet real power lies elsewhere. The parameters that will determine country allocations for 2027–2029 will be set by a Board still largely dominated by traditional donors. Decisions on how to manage the shortfall – which countries see their envelopes reduced, which programme areas are deemed “less essential”, which innovations will have to wait – will be taken more in Geneva, Washington, London, Brussels or Tokyo than in Abidjan, Kinshasa or Maputo.

For African countries, three risks stand out clearly:

• The risk of brutal cuts to community and prevention programmes, often perceived as less “essential” than commodity procurement. In times of budget stress, the first lines to be sacrificed are frequently those that do not immediately translate into a simple number, even though they are decisive for testing, adherence and tackling stigma.
• The risk of “transition by default” for middle-income countries, especially in Southern and North Africa, pushed to reduce their reliance on the Global Fund without domestic or regional resources truly filling the gap. Behind the word “self-reliance” may lurk a simple substitution: fewer grants, more out-of-pocket payments by patients or more debt.
• The risk of even greater fragmentation of financing if the response to the shortfall is to multiply vertical mechanisms, narrowly targeted catalytic funds, “blended finance” instruments and other sophisticated solutions that make sense to investors, but far less to ministries of health.

Yet the crisis of the 8th replenishment can also be a moment of clarity. For African actors – governments, civil society, researchers, communities – the task is to use the coming months to put numbers and faces behind this funding gap: how many community testing sites lost? How many treatment centres for drug-resistant TB at risk? How many bed nets not distributed in areas already facing resurging malaria?

This is also the time to articulate, in more political terms, the conditions for a “self-reliance” that is not a new name for health austerity: what real fiscal space exists? Which regional mechanisms (African Development Bank, regional health funds) can complement – not replace – the Global Fund? What role for the African Union in defining the rules of the game rather than merely implementing them?

In the end….

Johannesburg will likely be remembered as a powerful image: a tapestry of colourful fabrics, the voices of survivors, a South African president announcing “a defining moment for global health”. But for HIV, TB and malaria programmes from Dakar to Luanda, another image looms larger: that of a bridge half-built over a rising river.

“We cannot stop now”, artists and leaders repeated. Taking that phrase seriously means facing what an 11.34-billion replenishment really implies when 18 billion are deemed necessary: an urgent renegotiation of burden-sharing among major donors, strong pressure on the “silent” contributors to step forward, and an assertive African mobilisation that refuses both dependency and fake autonomy.

The Global Fund remains an irreplaceable instrument. But an under-funded instrument cannot, by magic, deliver on the promises we load into speeches. If this eighth replenishment is truly to be a “turning point”, it will not be because of the beauty of its staging, but because of the capacity of actors – North and South – to turn an awkward shortfall into an explicit political debate about what the world is really willing to pay to end three pandemics that continue to kill millions, primarily in Africa.

Public donors – 8th replenishment (conference on 21 November 2025)