3 Months to the Replenishment, Another Fork in the Road

An addendum to our ask FOR the 8th Replenishment

A lot of fear, and some hope

2025 has not been kind to global health. In the following paragraph, we do our best to quantify not the harm already done, but how much further we could fall. It’s not a pleasant read, if you care about people’s health and their lives. These numbers tell stories of massive hardship and lives lost, a lot of them for no good reason.

And yet, we want to open on a note of optimism. As you will see below, we did the math on the impact of the threat of U.S. scaling down their Global Fund contribution, which would be another blow to global health, after the cut of bilateral programs. Indications regarding the coming contribution to the Global Fund replenishment are cause for further alarm. Yet, for its size, the U.S. is just one of many countries. The magic of collective action is that it is not dependent on any single person, and thankfully, that is true of global health.

What would it take for other donors to fill the, still hypothetical, gap left by deep U.S. cuts in their contribution to the Global Fund? A 15% increase across the board.

15% is not enough for many things – it’s not enough to meet our 2030 targets and it’s not enough for our leaders to keep their promises. But it’s enough not to give up, and if you ask us, it really is a small, and doable, price to pay.

A few months to replenishment

We are now entering the last months of the Global Fund 8th Replenishment campaign, somewhat later than usual. Since 2016, the end of the replenishment was in September (for the 5th and the 7th) or October (for the 6th), because pledges had to come in before the autumn board meeting, typically held in November. This time around however the Global Fund board has, on the advice of the Global Fund Secretariat, decided to push back the autumn board meeting to February 2026, moving back the deadline for pledging to, accounting for the time necessary to prepare board documents and other logistics, December 2025. The rationale for pushing back the board meeting and giving more time for donors to pledge has not been made explicit, but one can take an informed guess: the global context is not favorable to ODA, economic and geopolitical uncertainties have reached new highs, and so more time will help champions make their case, and hopefully see a turnaround in global mood.

As of now, six months from the deadline, where do we stand? Early pledges have been largely positive. Spain and Luxemburg both announced increases, Norway announced it would maintain its contribution, the Children’s Investment Fund Foundation quintupled its pledge, Takeda Pharmaceutical announced a modest cut and Australia that it would maintain its pledge, in Australian dollars, which amounts at current change rate to a slight cut in USD. But no new large donor has come forward and it is likely that the fate of the replenishment will, once again, depend first and foremost on the pledges of the G7 countries. In 2022, together with the European Commission, they represented over 80% of pledges, and it does not look at this year will be much different.

Only one G7 countries has provided some indication of how much they intended to pledge: the United States. In the draft FY 2026 White House budget, an evolving document that will almost certainly change (see the KFF summary and analysis and the official White House page), we can read that the administration wants to put two conditions on the US pledge:

  • The United States’ contribution would not exceed 20% of all other pledges. This would be a change of the current ceiling of U.S. contribution, which limits it to 33% of Global Fund budgets.
  • The U.S. contribution would not exceed $2.4bn over 3 years; this is about half as much as the current level of U.S. funding.

We wanted to use our modelling tool to get a sense of what this would translate to. It is likely that the way funds are used by the Global Fund, in particular the split across operating expenses (OPEX), Catalytic Investments, and country allocation, will change because of the outcome of the Replenishment. In particular, it is unlikely that OPEX for the Global Fund remain at their projected level if pledges go down. Still, it is useful to get a sense of what “business as usual” would look like at different levels of funding. We’ll look at 3 scenarios:

  1. Resignation: What could be the impact of the U.S. cuts, on their own
  2. Catastrophe: What could be the impact of these cuts accompanied with a broader donor withdrawal?
  3. Staying on course: What would it take to compensate for U.S. cuts?

Scenario 1: Resignation

 

If we assume all other funders maintain their pledges from 2022, and the pledges already announced remained unchanged, what would be the impact on the Global Fund of the level of U.S. funding announced in the draft FY 2026 White house budget?

With our tool, we can give you a short and a long answer. Let’s start with the short one. If the U.S. funding level dropped to the levels indicated in the current bill, Global Fund pledges would go down 22%. At these level of funding, one can project impact on 2027-29 program outcomes:

  • 9 million fewer people receiving ARVs, and 230,000 fewer mothers receiving treatment to prevent vertical transmission.
  • 4 million fewer people would be treated against tuberculosis and 38 million fewer people screened for TB.
  • 52 million fewer people will be treated for malaria, and almost 200 million fewer mosquito nets will be distributed.

Overall, one can project that at that level of funding, approximately 2.3 million fewer lives will be saved by the Global Fund partnership over the next grant cycle, because of the scaling down of the Global Fund’s operation alone. Further negative impact is expected from the cuts to USAID, including PMI, and PEPFAR.

Now for the long answer, because the details matter here.

First, a note that in this scenario, the change of the cap on the share of U.S. contribution from 33% to 20% will have no impact – if the U.S. cuts its pledge by half and all other funders maintain theirs, mechanically the U.S. contribution will fall under 20% and the cap won’t come into play. The change to the U.S. matching could still matter however, as we have heard from other advocates, by discouraging donors outside of the U.S. from pledging, since they used to be able to count on each of the dollar pledged to “really” add up to 1.50 dollar, thanks to the U.S. match.

Second, foreign exchange rates loom large over the final outcome. In 2022, the pledges came through in the middle of a period of international instability that had strengthened the U.S. dollar against most other currencies. This had resulted in lowering the value in U.S. dollars of the pledges made by European countries (pledging in euros) and by the U.K. (pledging in pounds) in particular. But since 2022, the euro and the pound have risen in value against the dollar (as of September 10th, by 18% and 15% respectively). If change rates remain at similar levels when pledges are made later this year, it would partly offset the U.S. cuts. Our tool allows to select whether to use 2022 change rates or current change rates to make projections, and as of today, the difference is close to USD800 million. In other words, if exchange rate stays steady and all other funders at least maintain their funding levels, pledges could reach USD13.1 billion. It would significantly lessen the impact on strategic targets, though we still project over 1.3 million fewer lives saved in that scenario.

Third, the U.S. cuts would have a disproportionate impact on catalytic investments. Funding to “Address Human Rights and Gender Barriers” would go from USD100 million (at USD15.2 billion and above) to 35 million, ‘NextGen Market shaping’ from USD300 to 130 million, and ‘Optimizing RSSH’ and ‘Climate and Health’ from USD75 and 110 million respectively to 0. Here one must again note that it is likely that in response to a very low replenishment, the allocation model would change to allow for some funding to all catalytic priorities. Still, massive cuts would be concerning because Catalytic Investments are meant to be leveraged by country allocation, and to result in overall more efficient grants. If Catalytic Investments shrink in this way, one can imagine further impact on programmatic priorities, as a result of higher prices for commodities, operations more vulnerable to disruptions caused by climate change, and more key and vulnerable populations left behind because of systematic barriers.

Scenario 2: Catastrophe

 

Our first scenario might sound overtly pessimistic, but in the current environment it is far from a worse case scenario. The IHME just released their Funding Global Health 2025 report, which provides top-level estimates for global health funding. It projects that in 2025, funding will be 21% lower than in 2024. The U.S., projected to cut 67% of their global health funding, is the largest but not sole contributor to this decline. IHME projects the following funding levels across G7 countries: 

  • United Kingdom: 39% decrease
  • France: 33% decrease
  • Germany: 12% decrease
  • Canada: maintained
  • Japan: 2% increase

We can use IHME figures to make educated guesses for Global Fund pledges in G7 countries, assuming that pledges align with overall level of development assistance for health in each country.

Assuming here that change rate maintain and that these cuts are partly offset by the relative weakness of the U.S. dollar compared to 2022, putting these numbers into our model projects a USD11.8 billion replenishment – 24% lower than the 7th Replenishment – leading to major cuts in catalytic investments, a 17% drop in money available for country allocations, and over 2.4 million fewer lives saved for the next grant cycle.

Scenario 3: Staying on Course

 

The Global Fund’s mission, keeping at bay the world’s deadliest infectious diseases, is critical. The progress we have made in the past 25 years against HIV, TB and malaria have driven life expectancy gains, especially across sub-Saharan Africa, and brought the end of the three epidemics as threats to humans within reach. The United States have been a key partner in achieving these goals, both through their ambitious financial commitments and their complimentary programs funded through PEPFAR and USAID, but most of the Global Fund’s funding has always come from the rest of the world, especially Europe and Japan. We are living through a moment of double tragedy. The headlines focus on the withdrawal of the U.S. from health and ODA more broadly, but projected cuts from other funders will compound their effect. However, the U.S> cuts do not have to lead to a global setback. If globally we aimed at simply compensating for the US cuts to the Global Fund, pledges from other donors would have to increase, but not unreasonably. Let’s do more math.

The U.S. cuts represent about 22% of the Global Fund budget. Thanks to the gains in exchange rate, it would suffice that other donors increase their contributions by 10% increase to ensure country allocation remains stable for the next cycle. If other donors increase by 15%, country allocation would increase, and catalytic investments could be maintained. These are not ambitious numbers. They are lower than the increase for the 7th Replenishment for most donors. And much lower than what would be necessary for reaching the 2030 targets and keep our global commitments.

The perhaps shocking reality is that there are things we can do to make the world a better place that are neither hard nor expensive. Global health is one of them. We have built over decades a system capable of leveraging medical science to deliver impact at scale. This system can transform money – really, we are talking about pocket-change at the scale of global policy – into world-changing gains in health, life expectancy and economic growth. Global health has been an area where achievements have been most notable and reliable. Yet we are collectively choosing to underinvest in it, and in 2025 are hiding behind the actions of one country to pretend that we cannot do anything but give up.