The Golden Age of Global Health is Over. What Follows?

Abstract

This article examines the rise and fall of global health’s so-called golden age, from the 1990s to the early 2020s, a period marked by multilateral cooperation, historic funding increases, and major institutional innovations. It highlights the factors that have led to the decline—including funding cuts, political shifts, and emerging global crises—and argues for a reimagined framework for global health going forward. Recommendations include diversifying funding, empowering regional coalitions, adapting new governance models, and defending the principle of health equity. Without such reforms, the next era risks deepening global disparities in health outcomes.

Introduction

The late twentieth and early twenty-first centuries marked a transformative era for global health, characterized by unprecedented collaboration, funding, and innovation. The success of global health initiatives during this"golden age"was not solely driven by international efforts. Visionary leadership in low- and middle-income countries played a crucial role in translating global support into tangible health outcomes. Countries like Ethiopia and Rwanda exemplified how strong national leadership and comprehensive health reforms could effectively leverage development assistance for health (DAH). The support from organizations like Gavi, the Global Fund, and PEPFAR was crucial. This symbiotic relationship between international support and national ownership was fundamental to the credibility and sustainability of health improvements during this period (Reich MR, Takemi K, “G8 and Strengthening of Health Systems: Follow-Up to the Toyako G8 Summit,” The Lancet 373:508–515, 2009.

Binagwaho A, Hirwe D, Mathewos K. Health System Resilience: Withstanding Shocks and Maintaining Progress. Glob Health Sci Pract. 2022 Sep 15;10(Suppl 1):e2200076. doi: https://doi.org/10.9745/GHSP-D-22-00076.).

However, recent geopolitical shifts, funding cuts, and cascading crises have eroded these gains, signaling the end of this"golden age” which was characterized by a rapid growth. It involved the development assistance for health reaching a historic high of $28.2 billion in 2010 (Institute for Health Metrics and Evaluation. Financing Global Health 2012: The End of the Golden Age? Seattle, WA: IHME, 2012.)

This perspective examines the rise and fall of global health’s zenith and outlines a path forward amid growing uncertainty. While reduced funding from traditional donors poses immediate challenges, this shift also creates opportunities for democratizing global health governance and reducing dependency on a few dominant actors. The reordering may ultimately strengthen health systems if it catalyzes country ownership, facilitates universal health coverage, and sustainable domestic financing, which are objectives of development assistance. However, the risk lies in premature withdrawal of support before health systems achieve self-sufficiency, and the persistent need for financing of global public goods that transcend national borders OVI.

The Golden Age: Milestones of the 1990s–2000s

The golden age of global health emerged from a convergence of visionary leadership, institutional innovation, and heightened awareness of globalization’s health implications. Key milestones included the World Bank’s 1993 World Development Report, which reframed health as a driver of economic development and advocated for cost-effective interventions and equitable access [1]. The report also highlighted the importance of addressing noncommunicable diseases and mental health in all countries.

The Institute of Medicine’s 1997 report, America’s Vital Interest in Global Health, positioned U.S. engagement in global health as a strategic imperative, influencing bipartisan support for later initiatives [2]. The Rockefeller Foundation, through programs like Public Health Schools Without Walls and public–private partnerships, modernized global health governance while prioritizing technocratic solutions [3]. Its longstanding credibility enabled it to convene governments, academia, and nonprofits, catalyzing a fresh vision for global health.

Under Gro Harlem Brundtland (WHO Director-General, 1998–2003), WHO revitalized its credibility, brokered the Framework Convention on Tobacco Control (FCTC), and integrated human rights into health interventions [4]. Brundtland’s leadership galvanized multilateral and philanthropic investment in health for economic, security, and human rights reasons.

The Gates Foundation’s philanthropic investments, including a $750 million pledge to launch Gavi, catalyzed vaccine equity and scaled neglected disease research [5]. New institutions such as Gavi (2000), the Global Fund (2002), and PEPFAR (2003) accelerated access to vaccines and treatment for HIV/AIDS, TB, and malaria, saving millions of lives ⁱ. The near-eradication of polio, revised International Health Regulations (2005), and the FCTC exemplified multilateral progress.

This era was underpinned by soaring development assistance for health (DAH), which grew from $5.6 billion in 1990 to $41 billion by 2020. It was further supported by NIH investments in global health science and the efforts of organizations such as the Wellcome Trust, IDRC Canada, and Swedish SIDA (Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM, Jamison DT, Murray CJ. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet. 2009 Jun 20;373(9681):2113–24. doi: https://doi.org/10.1016/S0140-6736(09)60881-3. Erratum in: Lancet. 2009 Nov 21–2009 Nov 27;374(9703):1744..) Gavi's innovative financing mechanisms, particularly the International Finance Facility for Immunisation (IFFIm) and the issuance of vaccine bonds, revolutionized development finance for health. The IFFIm mobilized over $6.5 billion in advance funding based on the principle that investing in vaccines today protects future generations, thereby justifying the use of Official Development Assistance (ODA) for bond financing. This frontloading of resources enabled rapid vaccine scale-up and demonstrated how financial innovation could accelerate health impact. (Atun R, Knaul FM, Akachi Y, Frenk J. Innovative financing for health: what is truly innovative? Lancet. 2012 Dec 8;380(9858):2044–9. doi: https://doi.org/10.1016/S0140-6736(12)61460-3.)

Growth and Fragility: Development Assistance for Health in 2025

The 2025 Taking Stock of Development for Health report highlights DAH’s plateauing growth post-2020, with funding increasingly fragmented and earmarked. While PEPFAR and Global Fund allocations remained stable, The COVID-19 pandemic triggered an unprecedented surge in development assistance for health, reaching $70.6 billion in 2021. But at the same time it pushed low- and middle-income countries into severe debt distress. This debt burden now constrains domestic health spending when countries need to rebuild health systems and prepare for future pandemics (Institute for Health Metrics and Evaluation (IHME). Financing global health 2021: global health priorities in a time of change. Seattle (WA): IHME; 2023. https://www.healthdata.org/data-tools-practices/interactive-visuals/financing-global-health). The pandemic's dual legacy complicates narratives about global health's trajectory, revealing how emergency responses can mask structural vulnerabilities in health financing.. (Filip R, Gheorghita Puscaselu R, Anchidin-Norocel L, Dimian M, Savage WK. Global Challenges to Public Health Care Systems during the COVID-19 Pandemic: A Review of Pandemic Measures and Problems. J Pers Med. 2022 Aug 7;12(8):1295.doi: https://doi.org/10.3390/jpm12081295.) th.

To date, WHO faces a 21% budget reduction ($1.1 billion) for 2026–2027, threatening staffing and disease surveillance. (World Health Organization. Who budget crisis bigger than previously thought- $2.5 billion gap for 2025–2027. https://healthpolicy-watch.news/who-budget-crisis-bigger-than-previously-thought-2-5-billion-gap-for-2025-2027/) The World Food Programme has only 52% of its $16.9 billion operational requirements for 2025 funded, jeopardizing food aid for 25 million people. (UN News. WFP requires $16.9 billion in 2025 as hunger reaches alarming highs. https://news.un.org/en/story/2024/11/1157336) Reliance on donor pledges leaves immunization programs like Gavi vulnerable to political shifts.(npr. GAVI, the vaccine alliance, has its billion dollar grant cut by Trump administration. 2025. https://www.npr.org/sections/goats-and-soda/2025/03/28/g-s1-56881/vaccines-gavi-usaid-rubio).

The Unraveling: Forces Ending the Golden Age

Several forces are ending the golden age of global health. The 2025 U.S. administration’s freeze on foreign aid blocked $4.1 billion in global health funding, halting PEPFAR programs, malaria trials, and WHO contributions. Post-COVID austerity has seen donor nations redirect funds domestically, while low- and middle-income countries (LMICs) face debt crises that limit health investments. Cascading disasters, including conflicts displacing over 17 million people in the Middle East and Africa and climate shocks such as floods and droughts, further strain fragile health systems.

The U.S. government has been the largest single donor to global health since 2000, shaping global health architecture through major initiatives and emergency responses. Its funding, alongside philanthropic contributions, remains critical for addressing health crises, climate-related disasters, and conflict-driven emergencies. U.S. global health funding has averaged $12–13 billion annually since FY 2010, peaking at $12.9 billion in FY 2023. The U.S. provides 42% of all donor government health assistance, with 80% of funding supporting programs in nearly 80 countries, primarily in sub-Saharan Africa. Humanitarian aid has also been significant, with $10.5 billion allocated in FY 2024 for disaster and conflict relief [4].

Despite this, flatlined funding since 2010 and recent budget freezes threaten program continuity, particularly for HIV, malaria, and maternal health in crisis zones. Without sustained U.S. leadership, global health security and humanitarian response capacities face significant risks.

The retreat from multilateralism extends beyond the United States, reflecting broader political shifts across traditional donor countries. European nations, facing fiscal pressures and shifts in governance, have reduced or reallocated development assistance. The UK's merger of DFID with the Foreign Office and cuts to aid spending from 0.7% to 0.5% of GNI exemplify this trend (Worley W. UK cuts aid budget to 0.5% of GNI: what you need to know. Devex [Internet]. 2021 [cited (19 June 2025)]. Available from: https://www.devex.com/news/breaking-uk-cuts-aid-budget-to-0-5-of-gni-98640).

However, this retrenchment is not universal. Japan has maintained its health commitments while emphasizing universal health coverage, and emerging powers like India have expanded South-South cooperation. These divergent trajectories create a complex landscape where leadership voids may be filled by new actors with different development philosophies (Global Burden of Disease Health Financing Collaborator Network. Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990–2050. Lancet. 2021 Oct 9;398(10308):1317–1343.). Likely Impacts of Decreases in Global Health Aid.

Research on past donor exits highlights that some countries are particularly vulnerable to setbacks after losing aid, especially those with weaker economies, governance, and health systems.(Mao W, McDade KK, Ogbuoji O, Yamey G, Bermeo SB. Strategic donor behaviour and country vulnerability in health aid transitions. BMJ Glob Health. 2023 Nov;8(11):e012953. doi: https://doi.org/10.1136/bmjgh-2023-012953., Huffstetler HE, Bandara S, Bharali I, Kennedy Mcdade K, Mao W, Guo F, Zhang J, Riviere J, Becker L, Mohamadi M, Rice RL, King Z, Farooqi ZW, Zhang X, Yamey G, Ogbuoji O. The impacts of donor transitions on health systems in middle-income countries: a scoping review. Health Policy Plan. 2022 Oct 12;37(9):1188–1202. doi: https://doi.org/10.1093/heapol/czac063.) Strong health systems and proactive transition planning can help countries manage without donor support, but sudden, unplanned exits often cause disease resurgence, particularly among vulnerable populations, as seen in Romania’s HIV spike after the Global Fund’s abrupt departure.. In June 2010 the Global Fund HIV for Romania ended and in 2011 it becam ineligible for a new cycle due to upper-middle-income status. On that year HIV outbreak spread among people who inject drugs. (Romanian Harm Reduction Network. Joint statement of Romanian civil society organization in advance to the thirty sixth meeting of the Global Fund Board. 2016. https://rhrn.ro/en/joint-statement-romanian-civil-society-organizations-advance-thirty-sixth-meeting-global-fund-board/) Heavy reliance on a few donors, such as the U.S. in Kenya, exposes countries to severe service disruptions when funding is cut. (McDade KK, Munge Kabubei K, Kokwaro G, Ogbuoji O. Reducing Kenya's health system dependence on donors [Internet]. Washington DC: Brookings Institution; 2022 Mar 9 [cited 2025]. Available from: https://www.brookings.edu/articles/reducing-kenyas-health-system-dependence-on-donors/) Recipient countries are urged to accelerate domestic health financing and improve spending efficiency, but the poorest and most fragile states will still need external aid. Planned, gradual donor transitions and strengthened domestic systems are essential to sustain global health gains.

Estimates suggest that PEPFAR cuts alone could result in up to 460,000 additional AIDS-related deaths in children by 2030, alongside 1 million new pediatric HIV infections. (Cluver L, Makangila G, Hillis S, Ntwali-N'Konzi JP, Flaxman S, Unwin J, et al. Protecting Africa's children from extreme risk: a runway of sustainability for PEPFAR programmes. Lancet. 2025 Apr 8 [cited 2025 Jun 19]. doi: https://doi.org/10.1016/S0140-6736(25)00401-5.) One long-term benefit of international research funding has been the establishment of collaborative networks spanning countries, cultures, and health risks. These networks are now under threat, as recent NIH decisions to halt funding for research projects with foreign collaborators jeopardize the benefits of global scientific cooperation. For example, South Africa stands to lose up to 70% of its research funding as the NIH cuts approved grants to the country. (Mthethwa S, Low M. The US's NIH funds R6.65 billion of research in South Africa. Mail & Guardian. 2025 Apr 30 [cited 2025 Jun 19]. Available from: https://mg.co.za/health/2025-04-30-the-uss-nih-funds-r6-65-billion-of-research-in-south-africa/).

Beyond geopolitical tensions and funding cuts, the unraveling of global health's golden age reflects deeper institutional failures. A growing body of literature documents how complacency within global health organizations led to significant inefficiencies, duplication of efforts, and fragmentation of health systems. Critics have long argued that vertical disease-specific programs, while achieving targeted results, often undermined the development of comprehensive universal health coverage, public health and and primary healthcare systems, as well as preparedness and readiness activities in recipient countries The proliferation of global health initiatives created parallel systems that competed for scarce human resources and created reporting burdens that diverted attention from integrated service delivery. (Spicer N, Agyepong I, Ottersen T, Jahn A, Ooms G.'It's far too complicated': why fragmentation persists in global health. Global Health. 2020 Jul 9;16(1):60. doi: https://doi.org/10.1186/s12992-020-00592-1. PMID: 32646471;).

The shifting balance between bilateral and multilateral financing channels reflects deeper tensions in global health governance. While multilateral mechanisms theoretically offer greater coordination and reduced transaction costs, the rise of bilateral programs often reflects donor preferences for visibility and control. This trend toward bilateralization risks further fragmenting the aid architecture unless accompanied by strong coordination mechanisms. Recipients must navigate increasingly complex funding landscapes while asserting their priorities. The challenge lies in preserving the benefits of multilateral coordination—standardized procedures, pooled expertise, economies of scale—while accommodating diverse donor preferences and ensuring recipient country leadership in priority-setting.

A Call to Action: Reimagining Global Health

To avert backsliding, the global community must adopt redesigned architecture:

Diversify Funding

China is rapidly expanding its influence in global health through strategic investments in biotech innovation, infrastructure development, and multilateral partnerships, while the U.S. retreats from international health leadership. China has prioritized health infrastructure in low- and middle-income countries through its Health Silk Road, part of the Belt and Road Initiative. Its biotech sector, driven by initiatives like Made in China 2025, now accounts for 23% of the global drug pipeline, with significant advances in CAR-T therapies, antibody–drug conjugates, and bispecific antibodies. CAR-T treatments in China cost 50–80% less than in the U.S., and partnerships with Pfizer, Roche, and Merck highlight China’s innovation capacity. China plans to double biomanufacturing investments in 2025, targeting synthetic biology and industrial biotechnology.

China has also increased financial and political support for WHO, pledging $175 million in assessed contributions for 2024–25 and $5 million for traditional medicine programs. However, voluntary contributions remain modest compared to the U.S. ($30 million in 2024 vs. $700 million from the U.S.). China promotes traditional Chinese medicine through WHO partnerships, including a 2025–2034 strategy to integrate it into global health systems [4]. Critics note China’s preference for bilateral over multilateral aid, which amplifies its diplomatic leverage.

China's emergence as a development partner presents both opportunities and challenges for global health financing. While China's health cooperation, particularly through the Belt and Road Initiative's health component, has expanded access to infrastructure and medical supplies, questions remain about transparency, debt sustainability, and alignment with recipient country priorities (Tang et al., 2017). The global health community should engage constructively with emerging donors like China, India, and Gulf states to establish shared principles around aid effectiveness, while learning from their different approaches to development cooperation. Diversification of funding sources is essential, but must be accompanied by mechanisms to ensure coordination, country ownership, and accountability.

LMICs must increase domestic health spending, though this is challenging for the poorest countries. Expanding philanthropic support from regional and country-based foundations is essential. According to the OECD, over half of the 205 philanthropic organizations surveyed between 2016 and 2019 are based in emerging markets, providing USD 7.9 billion-19% of total philanthropic flows for development. (Organisation for Economic Co-operation and Development. Private philanthropy for development: second edition: data for action. Paris: OECD Publishing; 2021. doi: https://doi.org/10.1787/cdf37f1e-en). In India, China, and Mexico, domestic philanthropic financing for development now surpasses cross-border flows [5]. Some have highlighted the risk that private philanthropy in global health. While philanthropic funding has catalyzed innovation and filled critical gaps, concerns persist about accountability, priority-setting, and the sustainability of philanthropic commitments. (Morena, E. Linsey McGoey, 2015, No such thing as a free gift: The Gates foundation and the price of philanthropy, London, Verso, 304 p.. Rev Agric Food Environ Stud 98, 323–326 (2017). https://doi.org/https://doi.org/10.1007/s41130-018-0064-y).

Health and reproductive health remain the top sectors for philanthropic funding. While artificial intelligence holds promise for improving WHO's operational efficiency, emerging evidence reveals both opportunities and limitations. AI applications in disease surveillance, such as WHO's EIOS system for epidemic intelligence, have enhanced early warning capabilities. However, challenges include algorithmic bias, limited applicability in low-resource settings with poor digital infrastructure, and the need for human oversight in complex decision-making (Panch T, Pearson-Stuttard J, Greaves F, Atun R. Artificial intelligence: opportunities and risks for public health. Lancet Digit Health. 2019;1(1):e13-e14. doi:https://doi.org/10.1016/S2589-7500(19)30002-0;

Guo J, Li B. The application of medical artificial intelligence technology in rural areas of developing countries. Health Equity. 2018;2(1):174–181. doi:https://doi.org/10.1089/heq.2018.0037). WHO should pursue targeted AI applications where evidence demonstrates clear benefits—such as image analysis for disease diagnosis and predictive modeling for resource allocation—while addressing ethical concerns and ensuring equitable access to AI-powered tools (World Health Organization. Ethics and governance of artificial intelligence for health: WHO guidance. Geneva: World Health Organization; 2021. Available from: https://www.who.int/publications/i/item/9789240029200). WHO issued the first global report on AI in health and six guiding principles for its design and use (from: https://www.who.int/news/item/28-06-2021). -who-issues-first-global-report-on-ai-in-health-and-six-guiding-principles-for-its-design-and-use.

The private sector should be engaged through new public–private partnerships that leverage research, outreach, scale, and effectiveness. This requires a shift in WHO policy to embrace shared value for health, as outlined in Institute of Medicine reports [2]. Streamline Priorities:

Current WHO reforms focus on budget reduction rather than strategic realignment. WHO remains uniquely placed to lead global advocacy, develop science-based norms and standards, and provide trusted epidemiological data. The rising demand for emergency health response for crises affected populations, including refugees and displaced people requires new alignment among UN agencies, nonprofits, and regional health groups. Other emergency management aspects like prevention, preparedness, and readiness would benefit from aligning better with WHO efforts to strengthen health systems in countries.

New Governance Models

Regional coalitions, could decentralize power from Geneva and Washington. Evidence strongly supports this approach: Africa CDC has become a remarkably influential public health institution in a relatively short time, playing prominent leadership roles during outbreak response efforts across the continent. (KFF. Africa CDC: Its evolution and key issues for its future. Kaiser Family Foundation; 2023 Mar 30. Available from: https://www.kff.org/global-health-policy/issue-brief/africa-cdc-its-evolution-and-key-issues-for-its-future/) It operates through a decentralized model with five Regional Coordination Centres that work directly with National Public Health Institutes. (Africa CDC. Regional coordination centres Africa CDC; 2023 Mar 24. Available from: https://africacdc.org/regional-collaborating-centres/) In fact, Africa CDC's independent declaration of Mpox as a Public Health Emergency of Continental Security in August 2024 demonstrates its capacity for autonomous regional health security decisions. (Africa CDC. Africa CDC's Emergency Consultative Group recommends continuation of Mpox as a Public Health Emergency of Continental Security. Africa CDC; 2025 Mar 6. Available from: https://africacdc.org/news-item/africa-cdcs-emergency-consultative-group-recommends-continuation-of-mpox-as-a-public-health-emergency-of-continental-security/) Moreover, African health ministers have adopted their own eight-year regional strategy to transform health security, estimating $4 billion annually is needed to fund core health security capacities in the region. (WHO Regional Office for Africa. African health ministers adopt new regional strategy to transform health security. WHO; 2022. Available from: https://www.afro.who.int/news/african-health-ministers-adopt-new-regional-strategy-transform-health-security) WHO fully supports Africa CDC's elevation to an autonomous body Medicines for Malaria Venture, signaling recognition that regional leadership can complement rather than compete with global coordination. (WHO Regional Office for Africa. WHO supports the leadership role of a strong Africa Centre for Disease Control and Prevention. WHO. Available from: https://www.afro.who.int/news/who-supports-leadership-role-strong-africa-centre-disease-control-and-prevention).

The future of multilateral engagement in health extends beyond traditional health-specific organizations. The World Bank's expanded health portfolio, the World Trade Organization's role in intellectual property and pandemic preparedness, and the broader UN system's Sustainable Development Goals all shape health outcomes. However, these institutions face existential challenges in an era of rising nationalism and populism. The question is whether multilateral organizations can reform quickly enough to remain relevant while anti-democratic and isolationist movements gain strength. This requires a fundamental reimagining of how global institutions demonstrate value to skeptical publics and engage with diverse stakeholders including civil society, affected communities, and emerging powers.(Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, Fukuda-Parr S, Gawanas BP, Giacaman R, Gyapong J, Leaning J, Marmot M, McNeill D, Mongella GI, Moyo N, Møgedal S, Ntsaluba A, Ooms G, Bjertness E, Lie AL, Moon S, Roalkvam S, Sandberg KI, Scheel IB. The political origins of health inequity: prospects for change. Lancet. 2014 Feb 15;383(9917):630–67. doi: https://doi.org/10.1016/S0140-6736(13)62407-1.

Kickbusch I, Reddy KS. Global health governance—the next political revolution. Public Health. 2015 Jul;129(7):838–42. doi: https://doi.org/10.1016/j.puhe.2015.04.014.)

Robust private–public partnerships should be encouraged, building on the experiences of Gavi, the Mectizan program, and Medicines for Malaria Venture. Private pharmaceutical, medical devise, insurance, digital health, and related sectors need to expand their philanthropic and pre-competitive investments to strengthen research capacity in low and middle income countries.

Conclusion

The golden age of global health demonstrated the power of collective action. Its erosion demands not nostalgia but innovation: diversified funding, pragmatic prioritization, and inclusive governance. Without urgent reforms, the next era risks exacerbating inequities-a risk the world cannot afford.

Author Contributions

D.Y. conceptualized the idea. All authors (D.Y,. A.R., D.N) then contributed to drafting and final review of the manuscript.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

Ethics approval was not required for this review.

Competing interests

The authors declare no competing interests.