For too long, the conversation around global health funding has been dominated by voices from the Global North. When donor withdrawals happen, when budgets are cut, and when priorities shift, it is institutions in Washington, Geneva, and London that frame the narrative, often painting a picture of inevitable collapse for health systems in low- and middle-income countries. While the risks are real and cannot be minimized, this framing misses something critical: it strips away the agency, leadership, and adaptive capacity of the very people on the front lines of change.
This is the gap our project set out to address.
As part of the 2025 North America Leadership Journey, a leadership development program for mid- to senior-career women in health, we conducted eight in-depth key informant interviews with senior women leaders working in HIV, nutrition, and global health across Africa and Asia — including Senegal, Nigeria, Ethiopia, Mozambique, Kenya, Uganda, and India. These women lead national programs, non-profit organizations, and philanthropic institutions. They are not passive observers of global health transitions. They are architects of the response.
Using a semi-structured interview guide designed to enable open and candid discussion, we sought to understand how these leaders interpret the current moment, and how they believe the global health ecosystem must evolve. What we heard challenged many of our assumptions.
Funding Cuts as Catalyst, Not Just Crisis
One of the most striking themes across our interviews was the reframing of donor withdrawal, not simply as a crisis to be survived, but as a catalyst for long-overdue transformation.
As one interviewee put it plainly: “Sustainability means being honest about what the government can actually absorb.”
Interviewees described funding reductions as forcing a kind of productive reckoning. Hard choices are being made. Governments are beginning to assert ownership more forcefully, pushing back on donor priorities that don’t align with national strategies, and demanding that international partners work within locally defined frameworks rather than imposing parallel systems. The balance of power, however incrementally, is shifting.
The Limits of Vertical Programming
Another point of strong convergence was the critique of vertical, disease-specific programming. For decades, global health financing has flowed through siloed channels — separate funding streams for HIV, for nutrition, for maternal health — creating fragmented systems that countries are left to manage alongside each other rather than within a coherent whole.
Leaders were direct about the consequences. In Nigeria and elsewhere, vertical programming has led to inefficient use of health workers’ time and has prevented the consolidation of resources across platforms. As one participant described, donors sometimes go in with their own campaign priorities, forcing ministers of health into siloed implementation that serves donor timelines more than national needs.
The direction forward, according to these leaders, is integration: through shared platforms for human resources for health, laboratory systems, supply chains, and health information. This is not a new idea, but what is new is the urgency. Resource constraints are creating the conditions for collaboration among actors like the World Bank, UNICEF, and WHO that may not have felt necessary when funding was abundant.
Rebalancing Who Does What — and Why
A related theme was the need to fundamentally rethink delivery models. For years, non-governmental organizations (NGOs) and implementing partners (Ips) have served as the primary vehicles for service delivery. Our interviewees did not dismiss the value of these relationships, but they were clear that the model must shift.
Government funding, not donor-dependent implementing partners, should be the primary driver of service delivery. Where NGOs and implementing partners add genuine value (specialized technical capacity, community-facing functions, hard-to-reach populations) those partnerships should be preserved and strengthened. But the reflex to route funding through external implementers, rather than building government systems, must change.
Critically, leaders emphasized that this transition cannot happen at the national level alone. District-level capacity is decisive. Planning and management must be built below the national level, where services are actually delivered and where communities are most directly affected.
What This Means for How We Lead
Leadership in this moment requires adaptation rather than resistance. It requires the willingness to change course as realities shift, to re-examine our own roles, our assumptions about who leads and who follows, and how we can better support governments in building toward something durable.
The question is not only how to replace what is being lost. It is how we join forces across health verticals for more cost-effective, integrated delivery. How we build capacity intentionally rather than filling gaps. And how we ensure that the women already leading this transition are centered in the conversations shaping it.
These interviews are the beginning of that work, not the end.