Tag Archives: #FutureOfAid

A New Global Health Architecture: Maximising Health Returns

There have been a number of opinion pieces, resets, and declarations on what is needed in a new Global Health Architecture. These have been authored by diplomats, former Prime Ministers and Presidents, Multi-lateral agency staff and former staff, Philanthropies and peak bodies on what is needed in a new global health architecture. They have appeared in prestigious peer reviewed journals, on corporate websites, and here, I have attempted to synthesise the core messages and draw them together into an aggregate position that can help national governments action some of the ideas.

It starts with the contemporary global health landscape, which is increasingly defined by structural fiscal contraction, evolving geopolitical priorities, and the imperative to sustain health systems performance under conditions of constrained financing. In this context, legacy colonial models of development assistance—characterised by externally driven priorities, fragmented delivery channels, and open-ended commitments—are no longer fit for purpose. A transition toward more efficient, sovereign-aligned frameworks can deliver health at scale across well segmented population groups.

At the center of this transition is a reassertion of national sovereignty. Low- and low-middle income countries have historically been analysed through the lens of deficit-based models—most notably income, poverty and other World Bank style development indicators. In a context of increasing financial constraint and projected stagnation or decline in economic growth, that approach invites systemic failure.

A better alternative is an analysis of countries through the lens of asset-based models and indicators. This shift allows for a reorientation from needs-based allocation towards strategic engagement, in which financially flexible partners align with nationally defined priorities to co-develop fully costed health pathways. Such pathways provide end-to-end cost visibility, improving efficiency and accountability and enabling the precise calibration of health investments against projected returns. The well-established link between health improvement and economic productivity can be operationalised as part of national investment cases.

This reorientation will motivate a shift away from traditional sovereign lending, with its associated conditionalities, as the dominant financing modality. While sovereign lenders have played a critical role in expanding access and supporting system development, their balance sheets are increasingly constrained. Capital markets offer emerging mechanisms to complement sovereign financing in targeted areas where risk can be appropriately structured and priced. Through structured asset-pooling within and across countries, these mechanisms can enhance risk absorption and expand resource mobilisation. Over time, they may progressively relieve pressure on sovereign financing, enabling health systems to access more diversified funding streams while reducing exposure to fiscal volatility. This, in turn, may lessen reliance on sovereign conditionalities and allow national governments greater implementation flexibility.

Operationalising this shift requires the development of a coherent investment architecture. One approach is the development of Population Equity Units (PEUs), which serve as the foundational analytical and financial entities within national systems. These units can be aggregated into stratified Demographic Asset Classes, reflecting variations in projected lifetime contribution, health system utilisation, and responsiveness to intervention. The introduction of such classifications enables a more granular understanding of where investments are likely to generate the greatest returns for national governments alongside the highest health-valued gains.

To support decision-making across this architecture, a Health Returns Value Index (HRVI) can be employed. The Index would provide a standardised metric for comparing Population Equity Units based on anticipated health outcomes relative to cost. This facilitates outcome-weighted health investment prioritisation, ensuring that limited resources are allocated in a manner consistent with maximising aggregate health systems performance. Importantly, such an Index would allow for dynamic recalibration over time, as demographic, epidemiological, and economic conditions evolve.

Within this framework, national health systems can be conceptualised as Health Equity Portfolios. These portfolios comprise a diversified set of Population Equity Units across multiple Demographic Asset Classes, each contributing differently to overall system yield. Standard portfolio management principles can then be applied, including allocation, rebalancing, and risk mitigation. High-performing segments—those demonstrating strong alignment between investment and realised outcomes—can be prioritised for sustained or increased capital allocation.

Conversely, Population Equity Units falling below defined marginal value thresholds may require structured reassessment. In such cases, mechanisms for managed transition, including consolidation or phased divestment, can be introduced to preserve portfolio efficiency. These processes should be governed by transparent criteria and embedded within broader national planning frameworks to ensure predictability and stability.

The potential integration of capital markets provides an opportunity to further enhance the flexibility of this model. Population Equity Units can be progressively bundled into tradable instruments, including outcome-linked bonds and equity participation vehicles. These instruments allow external sovereign and market investors to assume a share of the financial risk associated with health investments, while aligning returns directly with measurable outcomes. In doing so, they create a direct linkage between system performance and capital flows, reinforcing incentives for efficiency and innovation.

A complementary development is the introduction of rating systems for Demographic Asset Classes. Drawing on established methodologies from financial markets, population segments can be assigned standardised ratings based on projected return profiles and risk characteristics. AAA-rated population segments—those with high expected returns and low variability—can be prioritised for long-term investment, while sub-investment grade cohorts may be subject to targeted de-risking strategies, including controlled exposure limits, selective disengagement, or phased reallocation of resources. Rating migration over time provides an additional feedback mechanism, enabling continuous optimisation of the Health Equity Portfolio, including downgrade-triggered reallocation where required.

One of the strategic advantages of this approach for national governments is the reconceptualisation of equity. Rather than being treated as a purely distributive principle, equity can be operationalised as a function of participation and alignment with system performance requirements. Under this model, Population Equity Units hold differentiated positions within the national portfolio, reflecting their contribution to and benefit from collective investment. This ensures that resource allocation remains responsive to both system performance and evolving demographic realities.

Institutionally, the framework aligns with a broader functional redefinition of global health actors. Multilateral organisations, including normative bodies, can focus on establishing standards, developing metrics such as the HRVI, and convening stakeholders across sectors. Implementation and operational decision-making are devolved to national and regional entities, consistent with the principle of subsidiarity. This division of labour reduces duplication and enhances system coherence.

Financing flows, in turn, become more targeted and time-bound. Development assistance becomes progressively redundant, reducing exposure to sovereign conditionalities, and financing is repositioned as catalytic capital, supporting transitions toward domestically anchored and market-enabled systems. Global public goods—such as surveillance, research and development, and epidemic preparedness—remain appropriate areas for sustained collective investment, given their transnational nature and positive externalities. Nonetheless, they would need to demonstrate measurable impact on the Population Equity Units, and a positive return on investment.

The proposed model is not without complexity. The introduction of new instruments, metrics, and governance arrangements requires careful design and sequencing. Data systems must be strengthened to support accurate classification, valuation, and monitoring of Population Equity Units, with the resulting data architecture constituting a high-value analytical asset class in its own right, potentially suitable for managed service provision or structured private participation. Regulatory frameworks must evolve to accommodate novel financing mechanisms while safeguarding system integrity. Capacity building at national and subnational levels is essential to ensure effective portfolio management.

The risks of inaction, however, are far greater. Persisting with fragmented, input-driven, and fiscally unsustainable models will undermine both efficiency and impact. By contrast, a transition toward a maximally efficient, return-oriented framework offers the potential to sustain and enhance health outcomes despite resource constraints.

The convergence of fiscal pressure, institutional reform, and financial innovation creates a significant opportunity to re-engineer the global health architecture around principles of equity, efficiency, alignment, and sustainability. Through the structuring of Population Equity Units, the deployment of the Health Returns Value Index, and the gradual mobilisation of capital markets, it is possible to construct Health Equity Portfolios that are resilient, adaptive, and performance-oriented. Such an approach ensures that, even under conditions of constrained financing, health systems can continue to deliver measurable value at scale for national governments.

Health system sustainability is preserved through disciplined alignment of investment with demonstrable population value.

Aid cruelty is not an opportunity

I have followed with genuine interest the responses of some sub-Saharan African (SSA) writers to the collapse of foreign aid in 2025. Whether they reside in SSA or enjoy a diasporic life in the Global North, they have argued that the loss may be an opportunity gifted to the Global South. While millions will die, SSA will at last be able to throw off the multi-billion dollar shackles to which it was so unwillingly chained. How awful to have been placed in the position of choosing between the “n”-word—“no”—and the “y”-word—“Yes!”—when offered money.

The tenor of the writing suggests that in making the offer of aid, countries in the Global South were stripped of agency. They could only rediscover agency when they were stripped of the money. The evil aid system by which the Global North klept [sic] them enthralled has at last been dismantled. The opportunity, long denied, has finally emerged to build health and development systems that “work for Africa”.

You will, I hope, forgive me if I do not join that cheer squad or Greek chorus.

In left-wing politics, there is an aphorism that it is better to suffer exploitation than starvation. To cheer unemployment for the liberating opportunities it provides from the excesses of exploitative capital is as short-sighted as it is stupid. That does not mean exploitation is acceptable. It is not. It must be resisted and fought. But starvation is not the solution.

If foreign aid was a shackle, its sudden removal should be freeing. But stripping away the existing system does not automatically lead to something better. Stretched governments cannot replace the wreckage of collapsed health programs overnight. What may look like liberation on paper is abandonment. A just transition requires negotiation and genuine collaboration. It requires time.

If the goal was to end aid, donor countries could have managed future aid through a phased reduction. The process could include such things as a shift to loans on beneficial terms combined with early debt management and relief. The development of capacity, systems, and infrastructure would need to be a part of it.

When you reach into the water to remove a life-jacket from a drowning man, you have not provided him with an opportunity to learn to swim, nor have you (passively) “let him die”. You have killed him. He may bob above the waves for a few minutes, even an hour. You may helpfully scan the horizon for a bit of passing flotsam for him to cling to. But when exhaustion finally overwhelms him, and he slips beneath the surface, you are a murderer.

When, with the snap of the fingers, a country closes HIV antiretroviral programs—leaving the drugs to rot and expire in warehouses and shop lots—it has not (passively) let people living with HIV/AIDS die. The donor country condemned them to death and waited.

The personal relationship with the individual drowning and the anonymous one with the hundreds of thousands of people on foreign-aid-funded antiretroviral does not change the moral calculus of the death, and it does not mitigate the callousness and wanton cruelty of the murder.

Aid programs are not light switches that donor countries can (or should) turn off on a whim. Cutting funding overnight destroys systems that took decades to build, leaving chaos in their place. The systems may not have been perfect; they may have needed greater local ownership in the design; they may have supported corruption. However, if the goal is genuine self-reliance, the responsible course is a phased, predictable transition that allows for capacity-building, infrastructure development, and systems design and refinement.

Millions have been condemned to death, others to lives of increased hardship and misery. If donor nations refuse to acknowledge their historical responsibility, then at the very least, they must be held accountable for the consequences of their actions today.

The world’s wealthiest countries’ substantial and immediate reduction in foreign aid turns their backs on the international human rights, their international obligations to support the SDG, and the obligation to leave no one behind. The United States (U.S.) led the pack when they put USAID “through the wood chipper”, but others have followed.

“The UK, the Netherlands, and Belgium have announced the largest cuts in [overseas development assistance] ODA history, and the European Commission, France and Germany are expected to follow soon. These cuts are not just minor shifts, but cliffs: at least USD 60 billion by USA and GBP 6 billion by the UK, EUR 8 billion over four years (2025-2028) by the Netherlands, and a possible EUR 20 billion by Germany.”

What is the unifying historical theme of these donor countries? Empire. They did not build their wealth on ingenuity or fair trade alone. Conquest, forced labour, and resource theft was there. They racialised the right to development. The UK drained its colonies of raw materials while imposing economic structures that prioritised British interests over local development. Belgium’s rule over the Congo was so extractive and brutal that its legacy still echoes in governance failures and economic instability today. France has reluctantly and only recently relinquished control over its former colonies, where it maintained economic dominance through ‘Françafrique’ policies that benefited Paris over Dakar.

Slashing aid is not an opportunity. It is abandonment. Do not let them disguise it as anything else. Do not allow the wealthy nations to pat themselves on the back for their cruelty. It is an outrage, and it must be named as such.

The outrage does not erase the agency of recipient countries that agreed to destructive conditionalities attached to receiving aid. It does not forgive the naked corruption that sometimes occurs. It does not excuse the capacity of poor countries to exploit their even poorer neighbours, nor the exploitation of social stratification within their societies.

But none of these realities justify the wholesale destruction of life-saving programs without a plan, without accountability, and without justice. Nations that built their wealth through exploitation cannot now walk away and abandon vulnerable countries, whether they were directly plundered by them or by others. If they do not uphold their obligations, civil society, recipient governments, and international institutions should demand an ethical transition rather than an overnight abandonment that costs millions of lives. Anything less is complicity in death.

Playing Fair: “Horizontality” and the Future of Aid

The arrival of US Aid, “from the American people”.

In his book, Playing Fair, the self-confessed Whig, Ken Binore argued for the redistribution of the “social cake”.

For progress to be made, it is necessary for the affluent to understand that their freedom to enjoy what their “property rights” supposedly secure is actually contingent on the willingness of the less affluent to recognize such “rights”. It is not ordained that things must be the way they are. The common understandings that govern current behavior are constructs and what has been constructed can be reconstructed. If the affluent are willing to surrender some of their relative advantages in return for a more secure environment in which to enjoy those which remain, or in order to generate a larger social cake for division, then everybody can gain. (p.7)

In other words, if we do not share the cake, “they” might burn down the bakery.

I am more idealistic. I have a sense that we should share the social-cake because it is the right thing to do, or maybe it is less the case that redistribution is right than it is wrong to leave people in states of significant disadvantage, particularly when one can do something about it. I am also sufficiently pragmatic not to care what motivates people to extend a hand to others.

Do it because it is right. Do it because it serves your own interests. Do it as a romantic, random act of kindness. I don’t care. The capacity of a dollar to make a difference is not altered. DO IT!

Let me extend this discussion to support offered by more affluent countries to less affluent countries. A couple of days ago I attended a virtual dialogue at Wilton Park as part of their “Future of Aid” series. “Aid” in this context is the (usually financial) assistance provided by one country to another.

Definition; Aid: Late Middle English from Old French aide (noun), aidier (verb), based on Latin adjuvare, from ad- ‘towards’ + juvare ‘to help’.

At least in conceptual origin, country-level aid is about one country doing something towards helping another country. And I would argue that what is really meant (or should be meant) by one country helping another country is that they are helping to improve the lives of the people who live in that country and, in particular, the less affluent and less powerful people.

An important idea emerged in the discussions about aid and that was “horizontality”. Horizontality is the idea that the donor and the recipient countries are equal partners. It is an attempt to move aid beyond neocolonial domination. I applaud this idea, at least I applaud the idea that we should not use aid as a vehicle for exchanging one kind of colonialism for another.

What I hope we are saying when we talk about horizontality is that aid is not about the exercise of power, it is about the redistribution of power. To achieve horizontality, aid can be neither handout, loan nor gift. Aid must be part of a just, redistributive process to improve lives and reduce suffering that recognises we all share one planet, and appreciates that donor and recipient governments are imperfect, though necessary, vehicles for realising these goals.

Horizontality does not mean that aid should be without conditions or accountability. In fact, it means the very opposite. Aid should have strong accountability mechanisms because the purpose of aid is to help people, and governments (and other involved commercial or civil society organisations) are simply vehicles for achieving that goal. The aid is from my people to yours.

If I give money to a homeless person, I am not asking for them to account for how they spend it. I am giving it to them because they need it. Maybe it goes on food or shelter, or maybe some momentary pleasure or relief from misery. If I give money, however, to a charity, I absolutely want them to account for how they spend it, because they are the means to the end and not the end in itself.

COVID-19 has brought the “future of aid” question into stark relief. We need better, more respectful mechanisms for delivering even more aid from more affluent countries to less affluent countries. The aid needs to come with strong accountability mechanisms to ensure that benefits are distributed according to an inverse power-law: the least powerful and the least affluent first. Aid, of all things, should not trickle down. When it does, governments on both sides of the aid-exchange should be held to account, by your people and mine.