In an era of shrinking aid budgets, the hardest question isn't what deserves funding. It's who gets to decide.
The contraction in global health financing has been abrupt. But the systems that govern it still assume a world in which more priorities can be added, more mandates protected, and more money eventually found. I felt that gap most clearly at a dinner alongside the UNITE Global Summit in Manila recently, listening to people from across global health make the case for their piece of a shrinking pie — vaccination, nutrition, HIV and malaria, NCDs, primary health care, pandemic preparedness, climate resilience, refugee response, water and sanitation. Nearly everyone at that table had real evidence behind their priority, and nearly everyone was right.
The challenge wasn't disagreement. It was scarcity.
Tradeoffs and prioritization have always been part of this work. Even when overall financing was expanding, individual diseases and programs still competed for attention. What growth did was let most of that competition play out at the margin: NCDs, climate resilience, and water and sanitation could join the agenda as newer priorities without displacing vaccination, HIV, or malaria funding outright. That release valve isn't available anymore. Development assistance for health has fallen from its 2021 peak of $80 billion to an estimated $38.4 billion this year — back to where it stood in 2009 — which means the tradeoffs aren't happening at the margins anymore. They're happening at the core.
And that changes the question.
Whether NCD advocacy is now less urgent than a vaccination campaign doesn't have a universal answer, because it depends on a country's disease burden, political economy, and what's already built. Which is exactly why that judgment belongs closer to the ground, not in a global ranking of which diseases count as most urgent.
But that authority is exactly what collides with the way much of global health financing still moves. A country can decide NCDs matter more this year than they used to — but if the financing on offer is earmarked for vaccination, malaria, or HIV specifically, that domestic judgment doesn't determine what actually gets funded. Someone else's mandate does.
As financing contracts, that collision is no longer hypothetical. Countries are increasingly being forced to make these choices in real time. WHO projected that external health aid would fall 30 to 40 percent in 2025 compared with 2023 levels, with countries already reporting disruptions to essential services like maternal care, vaccination, and disease surveillance. But what caught my attention is where WHO is focusing some of its response. Alongside emergency financing guidance, WHO is now working directly with countries on how to absorb it, and stood up a joint UHC Knowledge Hub with the World Bank and the Government of Japan specifically to help health and finance ministries find fiscal space together. That last detail matters, because it's an admission that the hardest part of this moment isn't technical. It's deciding what survives, what changes, and who gets to make that call when a country can't fund everything at once.
A principle with no enforcement mechanism
"Country ownership" has been part of the development lexicon for so long that it's hard to find anyone willing to argue against it. It's the organizing principle behind the Lusaka Agenda, the 2023 framework that committed global health institutions to align behind country-led plans. The regional dialogues Wellcome commissioned in 2025 reached a similar conclusion, including the Europe and North America dialogue co-led by Panorama Strategy and SEEK Development: financing needs to become less fragmented and align behind credible, nationally led plans and budgets. CGD's New Compact for Health Financing has spent the past year working outwhat that actually requires of donors once countries are doing the prioritizing— a serious attempt to answer a question most of the sector is content to leave rhetorical.
I'm more interested in what happens when the principle is tested, and the World Bank's own National Health Compacts are a useful, slightly uncomfortable place to look.
CGD's review of them points out that the compacts ask governments to commit to specific reforms and spending priorities without asking donors to make matching commitments in return — no requirement that aid move on-budget, use country systems, or align existing vertical funding with the plan the country just signed onto. A government can do everything asked of it and still watch its plan get quietly overridden by the accumulated earmarks of a dozen funders who never had to sign anything. That's country ownership in name and something closer to conditional cooperation in practice, and it's the clearest evidence I've seen that the country-led plan and funder priorities aren't the same thing — only one of them reliably survives contact with the money.
Where funding architecture meets delivery
I’ve seen what that can look like in practice through the work we did with ICONIQ Impact on its Child Survival Portfolio. It's a small example, and small examples matter here because they're still rare—but it shows what becomes possible when a funder starts not with institutional priorities or disease mandates, but with the delivery realities of the families and health systems it's trying to support.
Nutrition and immunization were a particularly instructive example: they're financed through distinct funding streams almost everywhere, despite converging on the same children, households, health workers, and delivery infrastructure. A child who's never been vaccinated is very often the same child at risk of malnutrition, and reaching her depends on the same community health worker, the same microplanning and geospatial data, the same functioning clinic and cold chain, and a mother who trusts the system enough and has the time to bring her there. From where that family stands, none of this needs to be justified as integration. It's just what the work requires.
That showed up across the portfolio in concrete ways. ALIMA, Aga Khan Foundation, and Edesia are each running integrated nutrition and immunization (INI) programs — pairing vaccination visits with nutrition supplementation in a single trip. NutriVax is the model much of this traces back to: a trial testing whether pairing supplements with immunization lifts both vaccination and nutrition outcomes. Other grants went toward the less visible infrastructure underneath all of it — microplanning, data, supply chains, reliable power for cold chains. Working backward from the outcome, rather than forward from a funding category, allowed the portfolio to support what delivery actually required. Grants were also unrestricted. What struck me in conversations with grantees wasn't gratitude so much as relief: unrestricted capital is still rare enough that most organizations don't expect it, and what it gave them was permission to stop redesigning their programs around what a funder was willing to pay for. It was a small, imperfect experiment in reversing the usual direction of adaptation — asking the capital to adjust, for once, to the realities of delivery rather than asking delivery to adjust to the capital.
Prioritization is political
None of this is an argument against specialization. Some global public goods genuinely require concentrated, protected financing that a purely country-led model would struggle to sustain. The question is whether the boundaries built for financing still match the boundaries that make sense for delivery, and how much they have to move when a country's own priorities cut across them.
With less money available, those boundaries become more consequential, and the instinct is often to reinforce them: protect the HIV line item, protect the immunization budget, protect the institution built around a specific mandate. It's understandable, and it's also how a shrinking pie ends up divided the same way a large one was, with everyone holding a smaller slice of their old turf. Real prioritization requires asking honestly where the need is greatest, what produces the most impact for the marginal dollar, and what has to be financed now specifically so it doesn't become next year's emergency —and none of that is purely technocratic. "The country" isn't a single rational actor any more than "the donors" are. Health ministers, finance ministers, parliamentarians, and civil society will disagree with each other the way funders disagree, and a government can neglect its own marginalized communities just as an external funder can.
Country ownership doesn't eliminate politics. It relocates legitimate political contestation closer to the people who live with the consequences.
That's a better system, not a tidier one, and the alternative isn't apolitical either. Donor earmarks, institutional mandates, and advocacy successes are political choices too, we've just had longer to get used to them.
Sometimes the funder has to lose
If funders actually believe in country ownership, there will be moments when the funder has to lose: when a foundation's preferred issue isn't the country's next priority, when a bilateral donor has to align behind a plan it didn't design, when an institution has to ask whether protecting its own mandate is serving the people that mandate exists for. That means accepting less attribution, less of a clean line between a specific dollar and a specific outcome, and directing money toward things that are essential and fairly unglamorous — health workers, procurement systems, district management, data infrastructure.
Philanthropy has a real opening here, not because it's more virtuous, but because it's one of the only kinds of capital that can give up control without answering to a legislature for it. The shift is small in wording and large in consequence: not "here's our priority, show us how you fit," but "here's the outcome we care about, tell us what it actually takes."
What it means to follow countries’ leads
The financing gap is real, and so is the case for closing it. But more money alone was never going to be a complete answer to scarcity on its own. A contraction this large should force harder questions about the architecture itself — where specialization still adds value, where integration would serve people better, and what happens to a country-led plan when it crosses institutional lines that were never built to bend.
For decades, countries and implementing organizations have gotten remarkably good at adapting themselves to the requirements of capital. If we're serious about letting countries lead, funders need to get just as good at adapting capital to the systems, priorities, and choices of the countries they say should be leading. Otherwise, we'll keep doing the same thing with less money, and calling it reform. Following countries’ leads requires something harder: accepting that country ownership only becomes meaningful when countries have the authority to make real choices— including choices their funders would not have made themselves.
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This article was originally posted on Linkedin.
Jennifer Shin is Director of Strategy at Panorama Strategy. Panorama Strategy worked with ICONIQ Impact on the Child Survival Portfolio and co-led the Europe and North America Regional Dialogue on Global Health Architecture Reform commissioned by Wellcome with SEEK Development. Views expressed here are her own.
