The future of global health is innovation
Global health is dead; long live global health.
That line that goes back to 15th-century France. When a king died, people said, “The king is dead. Long live the king.” It signalled both rupture and continuity—the old era ending, the new beginning immediately.
The U.S.-led, donor-driven model that defined the last 25 years is dead. And while global health isn’t disappearing, it is transforming—irreversibly. Unfortunately, that transformation will cost lives. A smoother transition would have been better.
From the early 2000s to the COVID-19 pandemic, global health funding soared—from just over $10 billion in 2000 to over $80 billion at its peak. The United States was the single biggest driver of this growth. Now that era is over. The US administration has proposed cutting global health spending from $10 billion to just $4 billion. Other countries are also cutting their foreign aid, and this may get worse as NATO raises its defence spending target to 5%. Last week, WHO warned of a “health financing emergency.”
At the same time, it's clear that the rhetoric of “country-led development” is no longer enough. For too long, donors said the right things about local ownership—while setting priorities in Washington or Geneva. What’s fading isn’t local leadership itself, but the lip service to it. In a world of limited resources, real country leadership will become a necessity, not a slogan.
And, finally, process is giving way to results. Global health has long been fixated on strategies, plans and steering committees. But when money is tight, nobody wants to buy process. They want to buy impact.
Replacing these traditional tenets of global health is innovation — in finance, delivery, and security.
Innovation in finance: The capital stack
The backbone of health systems will increasingly be domestic spending—augmented by smarter, more catalytic forms of external finance. This is the “capital stack” approach where each form of finance leverages and reduces the risk of the next.
Some domestic resources will come from taxes. Some from multilateral development bank loans.
With debt burdens and fiscal constraints, debt-for-health swaps, like those piloted by the Global Fund, or interest rate buy-downs, will grow in relevance.
Blended finance is gaining traction. The Global Health Investment Fund backed the only current supplier of cholera vaccine to the global stockpile. Other efforts, like the Health Finance Coalition’s Transform Health Fund, are pushing innovative finance from products to services.
Results-based financing is expanding. A Gates Foundation partnership with the European and Islamic Development Banks, for example, funds polio eradication based on results.
In fragile or conflict-affected settings, domestic resources will fall short. For these contexts, we need subsidy models, particularly for commodities, such as Gavi, the vaccine alliance, and the Global Fund. It may prove more sustainable in the long term to embed these models in regional bodies, where political bonds are stronger.
Will the UN save us? On the upcoming Financing for Development Conference I asked Chat GPT, “Why doesn’t the Seville document build on concrete examples of success in finance in an entrepreneurial manner?” The conclusion is below. The full response is worth reading. I am not sure I could have said it better.
Conclusion: A Technocratic Document in an Entrepreneurial Moment
The Seville outcome is cautious, not catalytic. It reflects the logic of intergovernmental diplomacy, not the urgency and ambition of entrepreneurial finance. As a result:
• It misses the chance to spotlight scalable success stories
• It fails to inspire a new generation of financial innovation in development
• It doesn’t bridge the gap between global commitments and local, investable change.
(It turns out there is a name for what I was doing: ‘vibe-teaming’. Admittedly, I may have been leading the witness with my question (a phenomenon known as ‘AI sycophancy.’)
Regarding the UN there are promising approaches in agencies such as the Health Impact Investment Platform. Ideally, these approaches start with the results one wants to achieve and work backwards to how to get them and then what mix of capital is needed. This sounds simple but as I have argued, the UN suffers from planning disease, focusing on inputs and activities over results. One cure is to work from right (results) to left (activities and then inputs) and link the results to financing.
What I’d like to see: More attention to the capital stack of investment. Building in an entrepreneurial manner on concrete examples. And better analysis—and ideally monetization—of revenue flows from these investments. That’s what will entrain even more private investment. That is the holy grail of innovative finance.
Innovation in delivery: The Next Development Model
As Dani Rodrik has argued, traditional development paths like product-based, export-led growth are no longer reliable, especially in an era of tariffs. The next path may be innovation in services—especially those that are better, faster, and cheaper.
And that’s exactly what’s happening in global health.
In Tanzania, the m-MAMA program is scaling nationwide. Think of it as the Uber of maternal health— increasing transports to hospital for pregnant women and decreasing costs.
In Zimbabwe, the Friendship Bench trains grandmothers to deliver culturally adapted talk therapy. In Uganda, StrongMinds and Group Support Psychotherapy are scaling talk therapy for depression.
In Kenya, Hewatele has reimagined medical oxygen delivery through a “milkman” model—placing production close to hospitals and slashing transport time and cost.
Other innovations focus on data. Sierra Leone’s Health Minister, Dr. Austin Demby, is building a digital system to track every pregnant woman in the country—her location, her risk factors, and the care she needs. This approach could contribute to a reduction in maternal mortality.
These aren’t boutique pilots. Some have scaled nationally. Others serve tens of thousands. Our job now is to take them to millions.
Programs like Science for Africa Foundation, Villgro Africa, and I3 Africa are incubating and growing more local innovations and enterprises.
Over the past 25 years development innovation has proven it can move beyond knowledge generation to impact. To make the change sustainable, let’s now tackle economic productivity as the next frontier in health and development.
The Grand Challenges approach helps to identify and overcome specific barriers, including in areas like literacy and public administration.
What I’d like to see: a Grand Challenge on productivity. It would support entrepreneurs to put innovations into companies, develop business models to find revenue streams, and identify pathways to grow their social impact while capturing the economic value of innovation. These elements could also be incorporated into existing grand challenges to guide selection of projects.
Innovation in Security: Rebuilding Trust
The next pandemic is not a question of “if.” Experts estimate a 50% chance of a COVID-scale pandemic by 2050. The new WHO pandemic accord is a step forward, but what matters is execution.
And successful execution depends on trust, which I have come to see as a fundamental issue in health security.
We face a broad crisis of trust in science and public health. Tom Bollyky and colleagues have shown that trust is a key determinant of pandemic outcomes.
Here are examples with potential solutions.
Trust in vaccine supply. We learned during COVID that if you want vaccines to be available in a pandemic, you have to make them yourself, at least regionally. mRNA platforms are fast, programmable, and flexible — and can be downloaded based on genomic sequence. When paired with genomic surveillance and diagnostics, they form a nimble triad of biological defense—like antivirus software for the biological world. Recent investments in vaccine manufacturing by Gavi, the Vaccine Alliance and at Institut Pasteur de Dakar are promising.
Trust in WHO. In a recent New York Times guest essay, I proposed two specific ideas to build trust. On pandemic response:
Doing more to recognize potential missteps — like not emphasizing airborne transmission of Covid early on — can help regain trust. When it comes to future pandemic responses, the W.H.O. should adopt the U.S. military’s approach of red teaming, in which groups are tasked with role-playing as an enemy to identify weaknesses in an organization’s operation. A version of this approach could help the W.H.O. identify flaws in how it responds to public health emergencies.
And on conflict:
The W.H.O. could also address criticism that the agency failed to properly condemn Hamas when it was accused of militarizing health facilities during the war in Gaza. It could create an independent group to review and recommend improvements to current practices around monitoring and reporting on militarizing these settings. This might draw the interest of the White House while helping to reinforce norms of international law.
What I’d like to see: greater attention to long-term ramifications on trust during short-term decisions in health emergencies. And initiatives to restore trust where specific solutions are available.
Strategic vs. Managerial: A Choice for Institutions
What I see in many institutions today is the triumph of managerial efficiency over strategic repositioning.
Whether WHO has 14 or 7 Assistant Directors-General will not decide the future of global health.
What will? Whether institutions are genuinely useful to domestic governments—the only true locus of political accountability in health.
In a funding crisis organizations tend to focus on their ‘core functions’ which sometimes take an organization back to its strategy of a decade earlier, rather than positioning it for the future.
In a world where countries are innovating on finance, delivery, security — that is what they need.
Organizations like the Gates Foundation and Grand Challenges Canada have shown how to back innovation and implementation. We need more of that thinking—more investment in innovation as a core pillar of international development.
And yes, we need a more results-based WHO (and indeed a more results-focussed UN system). I went to WHO hoping to help build an organization relentlessly focussed on results. Speaking only for myself, I failed to fully accomplish what I went there to do. But the groundwork has been laid—in the results report, triple billion targets, and delivery for impact — and the next steps are clear.
Looking Ahead
Global health is dead. As I wrote in the conclusion of my recent New York Times guest essay:
The golden age of global health as led by the United States is over. The rest of the world must now focus on building a healthier world that is less dependent on U.S. aid — and less susceptible to U.S. influence and disruption. Greater self-reliance is the path to truly sustainable development.
Some will argue the current system was not about charity but investment. First off, charity is a good thing. It just doesn’t scale and it’s not sustainable.
And there is no question that development improves human capital, and that is key for a productive workforce.
But the true test of whether something is an investment is when there is a revenue stream.
At a minimum I would say that the term ‘investment’ is overused in development.
Long live global health.
I am arguing that the future of global health will be country-led, results-driven, innovation-powered, and contribute to economic productivity. This is part prediction, part wishful-thinking, and part envisioning a future to work towards.
I would like to use this piece to spark a conversation. What do you see as a desirable future for global health?
Adapted from a speech delivered online at the Council on Foreign Relations, June 17, 2025. The piece also builds upon my guest essay in the New York Times published May 5, 2025.
The call for a shift from donor-driven to country-led, innovation-powered global health is not just aspirational—it’s essential for real, sustainable impact, especially as traditional funding contracts and health challenges grow more complex.
Building on your points about innovation in both finance and delivery, I’d like to highlight how digital transformation—especially the harmonization of health workforce and financing data—can be a game-changer for national health systems. As discussed in the recent LinkedIn piece on harmonizing National Health Workforce Accounts (NHWA) and National Health Accounts (NHA), aligning these frameworks with digital tools and location analytics enables countries to allocate resources more efficiently, reduce duplication, and foster transparent, accountable governance.
Rwanda’s experience shows that digital platforms and location-based insights can modernize data governance, providing a blueprint for “One Budget, One Country, One Location” approaches that directly support the kind of results-based, entrepreneurial investment you advocate.
Moreover, the examples you cite—like Sierra Leone’s digital maternal health tracking and Tanzania’s m-MAMA—demonstrate how scaling digital solutions can bridge service gaps and deliver measurable outcomes at national scale. These aren’t just pilots; they’re proof that digital innovation, when embedded in country-led strategies and supported by harmonized data, can drive the results-oriented transformation global health now demands.
To move from vision to action, as you suggest, we need to double down on integrating digital infrastructure with innovative finance models—leveraging blended finance, impact bonds, and results-based funding—to ensure these solutions are sustainable and scalable.
More details here : https://www.linkedin.com/pulse/from-vision-action-setting-service-delivery-urban-tiana-randriantsoa-zjqje/
A brilliant analysis of the state of global health, truly deserving of an in-depth discussion.
Here are just a few thoughts that come to mind:
I agree with many of the conclusions, though not all.
Yes, global health is in dire straits—but let’s face it, even with all the U.S. funding (which accounts for over 40% of all humanitarian aid), it has always been so.
Inefficiencies on the donor side, as well as corruption and complacency on the recipient side, have absorbed vast amounts of resources and, arguably, often hindered genuine progress toward Universal Health Coverage.
There are indeed positive examples of private capital contributing to the development of socially committed healthcare systems—France, Belgium, Switzerland, and Germany come to mind. However, we are also witnessing the creeping threat of the financialization of healthcare—that is, the injection of capital into the system with the sole aim of financial return. This trend, though perhaps an oversimplification, risks prioritizing profit over patient care, and its negative consequences are increasingly being observed and debated.
As most economies shift strongly toward the tertiary (service-based) sector, many low-resource countries are undergoing an even more dramatic leap—from primarily agriculture-based economies directly into the service era. In this context, investment in Universal Health Coverage should not be seen as an expense, but as an investment—and should be labelled as such.
This transition to tertiary economies is, for both rich and poor countries, a necessity in the face of automation and digitization. Failing to invest in it means stifling development. In healthcare, it also means leaving the ill, injured, and dying behind.