What will it take to reimagine global health for 10 billion people?

SUMMARY BOX.

• The fallout from US foreign aid cuts demands that the global health community not only respond, but reimagine what is possible for the future of equitable care.

• Global health has long relied on a siloed, disease-centric approach that creates vulnerabilities and concentrates funding, expertise and healthcare capacity in the Global North.

• To build resilience, we must invest in local capacity, especially through low-cost primary and preventive care delivered via pharmacies, community centres and clinics that are deeply rooted in the communities they serve.

• Recent health systems investments in Vietnam and Indonesia demonstrate proof of concept, while academic and non-governmental organizaiton (NGO)-led models for developing local talent can be scaled through national investment and public–private partnerships.

Introduction

The 7.7-magnitude earthquake that struck Myanmar on 28 March 2025 killed more than 3000 people.¹ The disaster also exposed the devastating impact of recent U.S. foreign aid cuts,² reductions that eliminated approximately US$9 billion in 2025—a 67% decline in U.S. global health funding.^{3 4} Humanitarian experts should have mobilised within hours, supported by emergency funding for a nation lacking strong disaster relief systems. Instead, those experts received letters of termination and were ‘told to go home by one o’clock’.⁵

Myanmar is a stark example of how the USA’s sudden retreat from the global health leadership will result in immediate, widespread suffering and death.^{1 6} Its heavy toll attests to a long history of fragmentation in place of collaboration and represents retrenchment when the world urgently needs investment—especially with the global population projected to reach 10.3 billion within our lifetimes.⁷

The fallout from US foreign aid cuts—including the dismantling of United States Agency for International Development (USAID)—demands that the global health community not only respond, but also reimagine what is possible.

Rebooting global health

What does that entail? The reboot starts with a shift from the current disease-centric approach that tracks mortality and morbidity to a model built on protective factors like universal healthcare, human capital and social cohesion. New model demands training local talent and building preventive and primary care systems that meet people where they are. And it requires public and private investments in community-level innovation and resilience and reducing dependence on foreign aid.

Had these strategies been adopted earlier, the slashing of US global health funding would be a surmountable challenge, instead of an existential crisis.

Current spending patterns reveal the shortcomings of disease-specific programmes that target HIV/AIDS, childhood infection and tuberculosis (TB). While these vertical approaches helped confront the AIDS pandemic⁸ and high under-five mortality⁹ in the late 20th century, continued progress now depends on addressing the transformative forces that shape population health, such as rising migration, climate change, inequality, state-based conflicts, and misinformation.

These forces most acutely affect vulnerable population groups. Take the 500 million adolescent girls living in lower-income and middle-income countries (LMICs).¹⁰ Under a vertically financed, aid-driven healthcare delivery model, a young woman living in an informal settlement in Kenya might visit a foundation-funded clinic for reproductive care, a the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)-supported pharmacy for HIV prevention and treatment, and an NGO-backed regional hospital for TB diagnosis. Such fragmented delivery mechanisms complicate access to care and hinder development of integrated, sustainable health systems.

Towards a new investment model for global health

This is an opportunity to leverage what has already been built and redirect investments towards more pragmatic solutions—community health centres with preventive services, local pharmacies and primary care providers. Building holistic local capacity also increases social cohesion and resilience against climate and economic shocks.

These strategies require strong national commitment, and some countries are already demonstrating what is possible. Vietnam invests 4.6% of its gross domestic product (GDP) in healthcare¹¹—approximately US$137 per capita—and has achieved 89.3% insurance coverage¹² through government-funded programmes and targeted subsidies for vulnerable groups. Similarly, Indonesia’s nationwide screening programme, launched in 2025, advances health equity by providing comprehensive health assessments for non-communicable diseases across its population of 280 million citizens.¹³

Both nations have shifted focus from reducing disease-specific mortality to improving life expectancy and quality of life, with a focus on expanding health access for vulnerable population settlements. But they did more than this. Vietnam and Indonesia have redirected funding, power and expertise towards local institutions, showing how domestic investment multiplies the impact of every dollar spent and accrues additional value over time.

I have seen the benefits of capacity-building firsthand as department chair at Columbia University, where students gain world-class training and skills that they can bring back to their communities and home countries. But this is, at best, a partial solution: developing more resilient healthcare systems in LMICs requires robust local medical and scientific education capable of producing skilled professionals on the ground.

Civil society can also make powerful contributions under this new model. The Population Council and MSI Reproductive Choices, my former employers, accelerate their impact by recruiting and training thousands of clinical staff, scientists and leaders from the very communities they serve. Their investment enables those individuals to shape their communities’ health futures. The African Population and Health Research Center in Kenya began as a Population Council research fellowship and has since become an independent regional powerhouse distinguished by innovative public health research and bridge-building collaborations.

Those successes point towards another critical piece of the health systems puzzle: creating technologies, policies and infrastructure that enable research and development (R&D) in areas ranging from healthcare access to climate resilience. That is possible only by harnessing the scale and influence of the government, the innovation and resources of the private sector, and the agility of civil society and philanthropy.

Rebooting global health will require mobilising every available resource: the remnants of USAID, ambitious South-South partnerships, philanthropists rising to the occasion, and emerging international sources of finance—among them, Chinese infrastructure spending. After 12 years and US$1.1 trillion, China’s Belt and Road initiative now emphasises ‘small and beautiful’ investment—that is, community-scale projects in clean water, agriculture and technology.¹⁴ Investments in societal infrastructure should be at the top of any agenda to re-envision global health. Expanding health systems, education and community capabilities will empower local partners and deepen the pool of local talent, benefiting all parties, increasing resilience and improving population-level health outcomes.

Conclusions

Taken together, investments in people, educational institutions, R&D and community health systems will ensure that everyone retains access to healthcare even through natural disasters or geopolitical upheaval. The future of global health is local, equitably distributed and diverse. We need hundreds of new training institutions and research centres worldwide, all working in tandem to confront the world’s most urgent challenges. Excellence belongs everywhere.

For too long, global health leaders have embraced a model of external dependence. The current funding crisis holds an opportunity for clear-eyed vision and offers a rare chance for bold, swift action to re-envision the status quo. The global health community cannot afford to waste this moment.

Data availability statement

There are no data in this work.