From scarcity to ambition — reimagining global health strategies

As traditional aid models strain under political and economic pressure, countries are at risk of shrinking development goals to match shrinking budgets. But doing so would miss the moment entirely. The real crisis in global health may not be funding — it may be a crisis of imagination.

Ministers of health find themselves facing a period of exceptional complexity. Funding is diminishing, health needs are increasing and trust in institutions is being tested. The challenge ahead is not solely financial; it is fundamentally a matter of leadership.

Our council brings together former heads of state, ministers, and leaders from various sectors. We established this group not to debate the importance of leadership and management, but to take action on it. If we want stronger, more resilient systems, we must invest in the people who lead and manage them.

But leadership is more than just a skill set. It is a political and structural matter, deeply connected to questions of sovereignty, power and priority. The path to sustainable development starts with national leadership, vision, and systems that function effectively.

Reclaiming sovereignty in a changing aid environment

As traditional aid models shift dramatically, clarity of national leadership has become more important, not less. While countries have always borne responsibility for their development, periods of external financing have often blurred lines of authority and accountability.

Today’s environment demands a reset. National governments must be recognised not as implementers of externally defined programmes, but as the architects of their own development agendas. This shift requires partnerships that align behind nationally determined priorities, longer planning horizons, and global actors that support effective and impactful country leadership.

Don’t start with scarcity — start with ambition

Too often, health systems are built around the money available. We call for a different approach. Start instead with the question: What do people truly need, and what kind of system will serve them best?

Let us work backwards from the desired outcome: quality integrated health services that put people at the centre. What structures, financing mechanisms and capabilities are necessary to turn that vision into reality and ensure its sustainability?

During moments of crisis, it is tempting to scale down our ambitions and accept minimal progress or even damage limitation. Yet it is precisely under fiscal constraint that clarity of ambition matters most: without it, scarce resources are fragmented, short-term decisions crowd out reform, and systems drift further from what people actually need.

History teaches us that what drives transformation is elevating our aspirations — with clarity of purpose, long-term dedication, and courageous public and private leadership.

Institutions require more than just inputs

Infrastructure and commodities may be visible signs of investment, but they are not the whole picture. Systems are only as strong as the people who operate them. This means leadership and management are not just soft skills. They are vital capabilities, especially during times of change and upheaval.

Sustainable systems change also depends on aligned leadership across the wider ecosystem — within government, across public institutions, and in partnership with communities, the private sector and other societal actors — anchored by a clear public mandate and shared national purpose. We must challenge the common belief that these skills can be gained passively or learned on the job. They demand dedicated investment, coaching, mentorship and a culture that values long-term learning and behaviour change over short-term results.

A window for redesign

Recent events, including significant funding withdrawals and shifting donor priorities, have put many national public health programmes at risk. However, this moment also offers an opportunity to rethink and redesign. Governments can seize this inflection point to develop systems that are people-centred, integrated, and prepared for the future.

The Nigerian Health Sector Renewal Investment Initiative, unveiled by the president in 2023, with its whole-of-government compact, multi-stakeholder partnerships, and increasing domestic financing in a sector-wide approach, represents an example of necessary shifts in health development

In another example, the minister of health of Senegal has outlined a clear, three-part strategy for health transformation: strengthening institutions and governance to unblock delivery bottlenecks, leveraging digital tools to expand access, and diversifying funding through domestic resource mobilisation.

What sets these approaches apart is not the components themselves — many countries are pursuing similar goals — but the clarity of ownership. These are sovereign visions, shaped by local priorities, delivered by national teams and framed around the long-term health of their people.

In many contexts, these plans will also require governments to deliberately shape how private capital contributes to national goals and priorities, aligning markets, regulation and incentives.

What comes next?

The coming years will challenge the resilience of our institutions and the strength of our commitments. However, they also offer the possibility of a new era of public sector transformation — one driven not by crisis response, but by ambition.

To facilitate this transition, we urge all stakeholders in global development to:

• Invest in public sector leadership and management as essential foundations, not optional extras;
• Transition from siloed, approaches to integrated, country-designed systems; and
• Support long-term capacity, not just short-term results

As a council, we remain steadfast in our belief: strong systems are created by strong leaders. The most effective way to promote equity, resilience and results is to invest in institutions — and the people who lead them — for the long term.

Let 2026 be the year we stop asking what can be done with what is left. Rather, let it be the year we start building what is needed with the leadership we already have. DM

The High-Level Council on Leadership & Management for Development is a global collective of former heads of state, ministers and global leaders committed to elevating leadership and management as core pillars of sustainable development. Council members include Barbara Bush, Helen Clark, Julio Frenk, Dan Glickman, Wendy Kopp, Robert Newman, Muhammad Pate, Manuel Pulgar-Vidal, Jaime Saavedra and Ellen Johnson Sirleaf. For more information on the council, click here.