Atlantic Fellows for Health Equity (AFHE) brings together health professionals from around the world and across disciplines to build leaders, create solutions and grow community. As we celebrate our tenth anniversary, we are reflecting on what our community has learned and accomplished while looking ahead at the future of health equity.
Through The Future of Health Equity Blog Series, AFHE Senior Fellows share their perspectives on the challenges, opportunities, innovations and leadership that will shape health equity in the years ahead. We are proud to bring these reflections to the BMJ Leader Blog audience as part of our 10-year celebration. The opinions reflected here are the views of the authors.
The blog below was written by Gafidyn Rae Wesonga, a 2025 Atlantic Fellow for Health Equity.
How Intimate Can Geopolitics Get with Our Health?
We tend to think of geopolitics as something distant: governments negotiating, alliances shifting, states competing for influence while redirecting their resources. But these geopolitical decisions are increasingly entering the most intimate spaces of ordinary life.
Global health financing is one of the clearest mechanisms through which this happens.
What we are witnessing today is not simply a shortage of money for global health. It is a change in priorities among wealthy donor countries. As high-income governments reassess foreign assistance and redirect public resources towards domestic priorities, defense, migration control and other geopolitical interests, global health is bearing the consequences. As a result, health agreements with African countries have become more transactional. For example, in order to receive critical life-saving funding from the United States, resource-limited countries must offer health data as well as access to critical minerals. Countries such as Zambia have opposed this.
These relationships are now shaping what health systems can provide, which services are available and to whom. They’re influencing whether health workers can be retained, community services can continue operating and if people can access care.
But what happens when global health becomes part of these bargaining chips on the wider geopolitical spectrum?
When donor governments change their foreign-policy priorities, reduce overseas development assistance, or redirect resources toward other strategic interests, those choices travel through international institutions, national governments, and implementing organizations before eventually reaching health systems and the affected communities they serve. The further the decision travels, the less political it appears.
The WHO estimated that international health assistance declined sharply between 2023 and 2025, placing essential services under strain across low- and middle-income countries. In a survey spanning 108 countries, governments reported interruptions to areas ranging from maternal and immunization services to emergency preparedness and disease surveillance. More than 50 countries have reported job losses among health and care workers.
Money doesn’t simply disappear from the global health system. Political priorities change.
A decision made in Washington, D.C., Brussels or another wealthy capital to reduce development assistance can appear elsewhere as just a funding gap. But that gap typically becomes a reduced program allocation, fewer health workers, weaker surveillance or less capacity to respond to an emerging outbreak.
The 2026 Bundibugyo Ebola outbreak in the Democratic Republic of Congo and Uganda shows what happens when geopolitical priorities meet health emergencies. With no approved vaccine or specific treatment, containing an outbreak depends on timely surveillance, preparedness and cross-border response. WHO and Africa CDC launched a US$518 million response plan, but it remains underfunded. Meanwhile, funding constraints are already disrupting more than 6,600 health facilities and limiting access to care.
Health systems do not operate on equal terrain. People affected by poverty, displacement, geographic exclusion, discrimination and social marginalization often have fewer alternatives when public and community services become constrained. The distribution of global health resources therefore matters not only for the strength of health systems, but for who is protected when those systems face pressure.
There is a legitimate argument that countries should reduce dependence on external assistance. And I believe they should. Having worked at the intersection of health systems, health equity and come-led advocacy in Uganda and internationally, I have seen how dependence on external financing can constrain national priorities and leave communities vulnerable to shifts in donor policy. Sustainable health systems require stronger domestic financing, greater national ownership and institutions capable of setting health priorities according to the needs of their populations. However, no country can achieve genuine health security if essential services remain vulnerable to decisions over which it has little control.
What does “financial independence” mean when low-income countries remain constrained by debt, illicit financial flows and an international tax system that limits their ability to mobilize domestic resources? Debt financing consumes public revenue that could otherwise fund social protection. High interest rates, short repayment periods, currency risks, and fiscal consolidation requirements force these governments to limit public spending while raising taxes. Meanwhile, profit sharing, tax avoidance, and other cross-border practices continue to drain resources from the same countries. Financial independence is not simply replacing external money with domestic money. It is changing the structures that determine who gets to raise, retain and spend resources.
Reducing dependence on external assistance and abruptly withdrawing it are not the same thing. A responsible transition should require predictable financing, coordination with national governments, assessment of health-system consequences and sufficient time to build domestic capacity. Otherwise, the risks created by unprecedented changes in donor priorities are transferred to countries and populations that have little influence over the decisions that created them.
For decades, global health has been discussed through the language of technical interventions, financing gaps and program delivery. But health outcomes are increasingly being shaped by political relationships, international power, economic interests, conflict, migration policy and changing priorities among states.
We need to revisit our definition of social determinants of health. Beyond income, education, housing, employment, and access to healthcare, we also need to recognize international political decisions, power relationships, and shifts in state priorities that shape the resources, policies, and conditions within which health systems operate.
As a result, we also need to bring more players to the table to shape health care and give those most affected by global health decisions a greater voice. Who determines global health priorities? Who decides which problems receive international attention and financing? Who determines when an intervention is no longer a priority? And who bears the consequences when wealthy countries change course? Communities, civil society, frontline healthcare workers, researchers, regional institutions, and governments in affected areas should have a role in answering these questions.
We need a global health system in which those closest to those problems define the solutions, where communities can hold decision-makers accountable, researchers provide evidence for locally identified priorities, and regional institutions can advocate collectively for their countries.
Author
Gafidyn Wesonga
Dr. Gafidyn Wesonga, MBChB is a physician, SOGIESC rights activist & community organizer, and a health/social justice advocate. A Makerere University graduate, she’s the founder of Initiative of Trans with a Mission—Uganda.
Declarations of Interest
No interests to declare.