2025 Broke the System. 2026 Decides the Future of Global Health.

Reflections on a year of political shocks, global realignments, and the signals we can’t afford to ignore. Predictions for 2026.

On January 20, 2025, the ground shifted. With a single set of executive actions, the new Trump administration took direct aim at the very field and community I’ve been part of for more than two decades. Global health—its institutions, its workforce, its multilateral commitments was seen as a liability to be dismantled. USAID, long the backbone of U.S. global health and development, was dismantled by early February, sending shockwaves through Washington, D.C., and capitals around the world.

In the U.S., the 90-day foreign assistance freeze fractured programs across dozens of countries, shuttered HIV prevention services, and destabilized long-standing partnerships. PEPFAR’s authorization expired without a plan. CDC’s global health footprint shrank. WHO funding disappeared overnight. Multilateralism, once a bipartisan asset, was recast as a liability.

But outside the U.S., something else happened at the same time: countries and regions began reclaiming the conversation.

These weren’t isolated policy shifts. They were part of a deeper pattern: a world increasingly governed by volatility—and by demands for agency. Climate disasters intensified. Dengue, cholera, and mpox spread across new geographies. Food insecurity deepened. Migration reached record levels as conflict, economic shocks, and environmental stress pushed people across borders. Trust in institutions continued to erode, but the appetite for reform grew louder.

I spent this year writing through that tension—sometimes documenting collapse, sometimes pointing to areas of alignment between US and Africa policy trends. The evidence was hard to ignore. Our modeling showed the cost of the aid freeze alone: more than 100,000 preventable HIV deaths and 135,000 preventable infant infections. Prevention—outreach, condoms, PrEP, harm reduction—was the first to go. Progress proved fragile when political foundations gave way.

Across regions, governments, donors, multilaterals, and civil society began openly questioning whether the global health model built in the late 1990s and early 2000s still makes sense. The old assumptions—stable donor dominance, linear transitions, siloed institutions, and permanent vertical programs—started to crack.

A Global Reckoning on Global Health

2025 became a turning point in how the world talks about the future of global health. Students began questioning why they entered global health at all. Those on the job market were left hanging—offers frozen, contracts pulled, career paths suddenly uncertain. A field that once promised purpose and stability now felt precarious, even brittle.

Across regions, leaders began saying more openly what many had long felt: the donor–recipient model is outdated. Health threats overlap. Financing is fragmented. Institutions compete more than they coordinate. Accountability still flows upward to donors instead of outward to communities.

The Accra Accord captured this shift—calling for sovereignty, integration, and shared accountability rather than dependency. It reframed global health not as charity, but as co-investment in resilience.

This year, I also helped launch the Kigali Call to Action, which pushed the conversation further: away from vertical silos and toward country-led systems that integrate continued HIV research and HIV prevention with NCDs, pandemic preparedness, climate resilience, primary care, and health systems strengthening. Kigali made explicit what many had only implied—that the HIV response was far from over and that a significant recalibration was urgently needed.

At the same time, long-taboo ideas moved into the mainstream: overlapping multilateral systems, consolidation where fragmentation undermines impact, a renewed focus on health systems strengthening, and open debate about whether institutions designed for the 2000s are still fit for the 2030s. That’s why serious voices are now openly discussing a Global Fund–Gavi merger and the collapse or full reconfiguration of UNAIDS—not as an attack on legacy, but as recognition that the architecture itself may now be a constraint on integrated, resilient health systems.

Some of this reckoning is long overdue.

The US Bilateral Health Agreements as a Stress Test of Reform

Since September, when the U.S. formally released the America First Global Health Strategy, events have moved quickly. What began as a conceptual reset has rapidly translated into a series of bilateral health agreements, negotiated and signed at speed. In a matter of months, MOUs have become the primary vehicle for redefining U.S. global health engagement—compressing timelines, reshaping expectations, and shifting responsibility to partner governments faster than many anticipated.

I’m also clear-eyed about where things stand right now with the current MOUs. You can read our analysis here. They reflect a decisive shift in U.S. global health strategy—away from vertical programs and toward integrated national systems, with strong emphasis on surveillance, labs, supply chains, data platforms, and rapid absorption of costs by governments. On paper, this aligns with what many partner countries have been calling for and what reformers—including myself—have long argued was necessary. It represents a real pivot toward national ownership and health sovereignty.

But this moment is also a stress test. The MOUs move quickly, with a high tolerance for risk: aggressive co-financing expectations, fast timelines for absorbing health worker salaries and operating costs, and limited margin for fiscal or political shocks. Integration is directionally clear, but often operationally thin. Without careful calibration, what is framed as integration could slide into cost transfer rather than genuine health systems strengthening.

I’ve worked on PEPFAR Country Operational Plans when transparency, consultation, and feedback loops were treated as core design features—not optional extras. Under Ambassador Nkengasong, we pushed to better align COPs with national systems while preserving what made them durable: community accountability, data discipline, and predictable engagement with Congress. Those elements matter more—not less—in a transition moment like this.

Durable health systems don’t rest on government signatures alone. They depend on buy-in from civil society, professional associations, community groups, and implementing partners who surface problems early and help manage risk before it becomes failure. Right now, consultation has been selective, civil society engagement uneven, and local private-sector voices largely absent. That imbalance is a real vulnerability.

That’s why transparency and oversight matter. MOUs should be public. Progress should be measurable. Congressional engagement should be ongoing. Oversight is not a partisan exercise; it’s how durable policy is built. If this is done well, the administration could rightly earn credit for enabling a long-overdue system-level shift demanded through the Accra Accord, the Kigali Call to Action, and the Lusaka Agenda. If it’s done poorly, the consequences will again be measured in lost trust—and lost lives.

What 2026 Will Decide

2026 won’t be a year of recovery or reset. It will be a year of tests—political, institutional, and moral. The choices already set in motion will either harden into a new equilibrium or unravel under scrutiny. Here’s what is most likely to define the year ahead.

1. Global health cooperation will continue to fragment.

Global health will not snap back to the old donor–recipient model. In 2026, we will see new ways of doing business, new partnerships, new financing mechanisms, new faces, and new operating models take hold. Regional platforms will grow in importance. South-South cooperation will accelerate. Power will continue to decentralize away from traditional donor capitals.

This shift will have real implications for multinational companies and the private sector, as new access models, co-financing arrangements, and public–private partnerships emerge to fill gaps once covered by traditional aid. That transition carries real risk—but also real opportunity if we get it right.

2. The U.S. bilateral health agreements will face their first real reckoning.

2026 will be the year the MOUs are tested not on paper, but in clinics, budgets, and lives. As financing transitions accelerate and absorption timelines tighten, these agreements will either prove that integration and sovereignty can coexist with service continuity—or reveal where ambition raced far ahead of capacity. Some will hold. Others will fracture.

By the time HIV leaders gather in Rio for the International AIDS Conference (#AIDS2026), the verdict may already be in. The question won’t be rhetorical: does the United States still intend to lead in global health—or has it chosen retreat, leaving a vacuum others will rush to fill?

3. Congressional oversight will reassert itself forcefully.

Congress will not stay on the sidelines. In 2026, expect more hearings, more demands for transparency, and sharper questions about how MOUs are being implemented, how risks are being managed, and what returns on investment actually look like. As this scrutiny intensifies, we are likely to see more fallout from countries—missed targets, strained transitions, and uneven impacts on services—as well as clearer evidence of where aid reductions are hitting hardest. Tools like The Aid Report are already beginning to surface these shifts, providing independent visibility into aid flows, gaps, and consequences. Oversight will become a central force shaping the next phase of U.S. global health policy.

4. AI will dominate the global health conversation—and force governance choices.

In 2025, artificial intelligence moved from the margins to the center of global health discourse. From IAS to ICASA, AI dominated conference agendas—shaping conversations about HIV prevention, service delivery, surveillance, and health systems performance. That momentum will only accelerate in 2026, spreading across global health far beyond HIV.

As AI becomes embedded in programs and policy, governance will move decisively into geopolitical territory. Debates over data ownership, algorithmic accountability, and cross-border data flows will intensify. Countries will align—or clash—around competing governance models. The forthcoming Lancet Commission on HIV and AI will help frame these debates, but implementation will be political. The winners will be those who pair innovation with trust, safeguards, and clear accountability.

5. NCDs—and GLP-1 access—will become unavoidable policy battles.

Despite failing to secure a dedicated NCD resolution at the United Nations, noncommunicable diseases will continue moving from the background to the center of global health politics. GLP-1s will force uncomfortable questions about affordability, market concentration, and equity—both in the U.S. and globally.

In 2026, pressure will mount on governments and health systems to expand access, manage demand, and confront pricing and supply constraints. Here, the HIV response offers a clear playbook: generic licensing, pooled procurement, political will, and civil-society pressure. Applying those lessons to metabolic disease will be essential—or we risk entrenching a new generation of health inequity.

How I’m Entering 2026

I didn’t spend 2025 trying to defend the old system. I spent it trying to understand what was actually changing—and what might come next. That meant keeping a reform mindset even when the ground was shifting, staying open to uncomfortable ideas, and resisting the instinct to retreat into familiar arguments just because they were once effective.

It also meant doing things differently. Building new partnerships. Listening more carefully to governments and actors outside the usual global health echo chambers. Testing new ways of working. Being willing to sit with uncertainty rather than rushing to tidy conclusions. That openness—however imperfect—has helped me stay effective and articulate in trying to name where this field is headed, not just where it’s been.

I don’t pretend to know exactly what 2026 will bring. But I do know this: the habits that helped global health succeed in the past won’t be enough on their own going forward. The ability to adapt, to collaborate in new ways, and to imagine a different kind of future—one that’s more distributed, more honest, and more accountable—will matter as much as funding or policy.

That mindset won’t just shape global health. It’s going to shape how we navigate climate, technology, geopolitics, and democracy itself. The work ahead won’t be neat. But staying open—intellectually and practically—may be the most important tool we have.