.The Global Fund Warning: What Happens When the World Stops Paying Attention to Disease?

By Ephraim Agbo 

On the margins of the G20 in Johannesburg this week a blunt arithmetic landed on the conference table: the Global Fund’s plea for US$18 billion to finance the fight against HIV, tuberculosis and malaria for 2027–2029 — a package the Fund says would avert some 400 million infections and save 23 million lives — met stiff reality. The replenishment closed with a significant shortfall, leaving governments, NGOs and health ministers to square urgent moral choices against tightening domestic budgets and shifting geopolitical priorities.

This is not a story about numbers alone. It is a story about what happens when long-run development pathways collide with abrupt policy decisions, donor retrenchment and fragile state capacity — and, vitally, what that collision means for people on the ground whose lives and livelihoods depend on those programs.

The Johannesburg moment: ambition vs. appetite

The Global Fund presented an investment case framed in technocratic terms — return on investment, lives saved, infections averted — but its urgency was political. The Fund argued that a fully funded replenishment would not only continue gains against three of the world’s deadliest diseases, it would buttress fragile health systems and reduce the chance that local outbreaks become global shocks. The modelling the Fund used to make that claim is clear and persuasive; the hurdle was political will.

Yet donor commitments fell well short of the $18 billion ambition. Reporting from Johannesburg shows partners pledged a total well under the ask, forcing the Fund to plan for cuts and reprioritisations. Beyond the immediate programmatic shortfall, the outcome exposes a deeper trend: multiple major donors are tightening aid budgets — and some governments have moved to restructure or repurpose the machinery of aid itself.

What the numbers mean: shortfalls at replenishment mean grants will be reduced or delayed, price negotiations will intensify, and the pipeline for new tools (drugs, diagnostics, nets) will weaken — all of which can translate rapidly into preventable illness and death in the most dependent countries.

The U.S. pivot and the politics of foreign assistance

At the centre of the shake-up is a major geopolitical actor: the United States. In 2025 the U.S. administration announced a sweeping reorganisation of how it delivers development assistance — a move that effectively dismantled the institutional independence of USAID, cancelled numerous programs and transferred many functions into the State Department. That pivot has not only reduced the raw volume of U.S. programming in some sectors, it has injected profound uncertainty into long-running partnerships and procurement chains.

For recipient ministries and implementing partners, the effects are immediate: projects that had been scheduled for phased handover now face abrupt funding gaps; procurement for antiretrovirals, TB drugs and bed nets is delayed; and technical-assistance programs that helped build district-level surge capacity are scaled back or cancelled. The political calculus in donor capitals — pressure to prioritise defence and domestic needs, fiscal retrenchment, and a ‘charity vs. national interest’ framing of foreign assistance — is reshaping what "partnership" means in practice.

Europe’s retrenchment — cuts, reallocation and ripple effects

Donors across Europe have also tightened their belts. Several major European contributors announced meaningful reductions in development budgets and philanthropic pledges over the past 18 months. The UK has made sharp cuts from about $18 billion last year to a projected $12 billion by 2028 after diverting more money toward defence. Germany has trimmed its development budget by 8% to around $11 billion, and its emergency humanitarian funding has been almost halved. France has gone further, cutting more than $2 billion from its 2025 development budget — nearly a 40% drop. Japan also has reduced its contribution; in 2024 its aid spending fell by more than 10% to about $17 billion, one of the lowest levels in years.

The consequences are cumulative: when a handful of large donors reduce funding in lockstep, multilateral instruments and pooled funds face multiplier effects that bilateral cuts cannot easily counterbalance. The political argument in capitals — voters first, defence second — is understandable to policymakers; its downstream effect is more fragile health systems in low-income settings.

Zambia: a case study in fragility and resilience

To understand the real-world impact of these aid shifts, consider Zambia. The connection between economic precarity and gender-based violence is starkly visible in fishing communities along the Zambezi, where women processing and selling dried fish have historically faced transactional sexual exploitation. Reported cases of gender-based violence surged from roughly 26,000 in 2020 to about 43,000 in 2023—a rise driven by economic stress and critical gaps in service delivery. Internationally funded development projects—including referral clinics, police training, and livelihoods initiatives—had begun to alter these bargaining dynamics by reducing the pressure on women to trade sex for fish.

However, this progress is now under threat. When international aid was reduced, the Zambian government in Lusaka responded admirably by increasing its health spending by 13% and boosting funds for essential medicines by 30%. Yet, this domestic fiscal response cannot immediately fill the void left by steady, predictable donor funding. 

Zambia’s situation encapsulates the central dilemma of this new era: while politically popular, domestic budget increases are often not a timely substitute for front-loaded donor investments in supply chains, clinic staff, and disease control. An abrupt reduction in external financing creates immediate gaps that volatile domestic revenues cannot close overnight, leaving vulnerable populations at risk.

Why a rushed “transition” is dangerous

A dominant argument among donors and some recipient governments is that countries should "graduate" from external support and finance more of their own health systems. That is a legitimate long-term objective — greater domestic financing is essential for sustainable health systems. But the evidence and expert opinion from practitioners are consistent: transition must be calibrated and sequenced. Sudden withdrawal of financing — without solid replacement revenue, procurement guarantees or governance safeguards — will produce programmatic backsliding, reagent stockouts and lower treatment adherence. In fragile or conflict-affected settings, the consequences can be catastrophic and hard to reverse.

Peter Sands, the Global Fund’s executive director, framed it as a journey that must not be switched off abruptly. Economists point to strong returns on health investment — improved life expectancy cascades into higher labour force participation, educational gains and GDP growth. For example Ethiopia saw a 16-year increase in life expectancy over 20 years, dramatic reductions in infant and maternal mortality, improvements in education, and an expanded labour force. Its GDP is 20 times what it was. The return on investment in health is huge — but those returns require persistent inputs, particularly for diseases that rebound quickly when control measures lapse.

Governance, corruption and the “value for money” debate

Donor governments frequently cite governance concerns — corruption, mismanagement — to justify recasting aid relationships or demanding more conditionality. Those are real issues and must be addressed; however, the political framing that equates aid reduction with solving governance problems is flawed. Tightening aid can reduce the leverage that donors have to demand transparency and reforms; it can also shift power to actors less accountable to domestic constituencies. The better path is conditional but patient engagement: tie financing to measurable governance benchmarks while protecting front-line life-saving services from political bargaining.

Policy implications and pragmatic steps

For donors, governments and global institutions, the Johannesburg replenishment should be read as an alarm bell, not a final verdict. Practical, near-term steps that would blunt the worst outcomes include:

• Prioritise front-line continuity. Protect funding lines for procurement and treatment continuity (ARVs, TB drugs, malaria commodities) from political reallocation.

• Scale flexible financing instruments. Use shock-responsive, conditional but flexible grants that can be rapidly reprogrammed in the face of crises.

• De-risk private investment for clinics and manufacturing. Push blended finance for local pharmaceutical manufacturing and diagnostics so that value addition stays in-country.

• Support phased transitions with clear metrics. Instead of abrupt handovers, create staged phase-outs tied to domestic revenue milestones, procurement capacity, and governance indicators.

• Preserve technical assistance and governance oversight. Retain long-term investments in audit capacity, procurement systems and anti-corruption mechanisms that yield outsized protection for public funds.

Conclusion — an equation of risk

The Johannesburg replenishment underscores a new policy reality: donor fatigue, geopolitical reorientation and domestic fiscal pressure have combined to reduce global appetite for long-term health financing at scale. The arithmetic is brutal: fewer dollars today will mean more preventable disease and death tomorrow, especially in fragile contexts. But there is another arithmetic — the economic case for health investment — which remains persuasive and unchanged: stronger health systems produce broader social and economic returns. The question for leaders in Johannesburg and beyond is whether politics will short-circuit an economic and moral calculus that, over decades, has demonstrably paid off.

If they do nothing else this week, global leaders should accept that the choice is not between donor-led aid or nationalist retrenchment alone; it is between managed, predictable transition and chaotic, deadly disruption. The Zambezi’s fishing stalls — and the women who work them — are already living the consequences of that political choice.