By Tian Johnson, the African Alliance
Shifawu Abdulkarim has spent 14 years as a community mobiliser and distributor in Kaduna State, Nigeria.
She says motherhood motivates her to do everything she can to protect children from malaria. Her work has likely helped to bridge the gap between global policy and local survival.
In one campaign, supported by the Global Fund, Shifawu joined nearly 12 000 mobilisers who distributed millions of insecticide-treated nets and delivered malaria chemoprevention to more than two million children under five.
She has been part of a health revolution that has saved up to 70 million lives by the end of 2024.
Since 2002, deaths from HIV, tuberculosis (TB), and malaria in countries that receive Global Fund support have fallen by nearly two-thirds; new infections have dropped by over 40%.
But the progress to which Abdulkarim has contributed is now under threat from funding shortfalls, political backsliding, and climate disruption.
Every three years, the Global Fund undergoes a “replenishment”. This is a high-stakes moment where donor governments, private foundations, and implementing countries commit the resources needed to keep the fight alive. Without this regular cycle of pledges, the Fund simply cannot function. The upcoming Eighth Replenishment will decide whether the world has the money to finish the job of controlling HIV, TB, and malaria, or whether hard-won progress will be rolled back.
South Africa’s role is pivotal. As the country with the world’s largest HIV epidemic, and as one of the Global Fund’s biggest recipients on the continent, South Africa is not just a beneficiary but a pace setter. Our national delegation sits on the Global Fund Board, shaping policies that affect dozens of other countries. If Pretoria signals ambivalence or turns inward, donors take note, and communities across Africa pay the price.
Yet South Africa also has leverage. It can use its voice to insist that replenishment is not framed as charity from the North to the South, but as a collective investment in global security. And it can press fellow BRICS nations to step up their own contributions, reminding the world that the fight against pandemics is indivisible.
The gathering storm
Just as the world edges closer to ending AIDS and controlling malaria and TB, the foundation of this progress is cracking. Development assistance for health, which surged during COVID-19, is now shrinking.
Although the tools to end HIV, TB, and malaria exist, the money to deploy them at scale does not. Without renewed commitments, clinics will shutter, supply chains will falter, and frontline workers like Shifawu may be forced to abandon the roles they built their lives around.
In 2025, Africa CDC reported a surge of malaria cases in sub-Saharan Africa, tracing outbreaks to efforts that began in late 2024
Funding is not the only threat.
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Political regression is eroding the rights frameworks on which global health depends. Across multiple regions, LGBTQ+ people, sex workers, and people who use drugs face criminalisation, violence, and stigma that block access to services.
These are not marginal concerns but epidemiological flashpoints: if those most at risk cannot access care, epidemics cannot be controlled. Anti-rights movements are increasingly coordinated and well-resourced, undermining decades of fragile trust.
Changing climate, changing risks
Climate change adds another destabilising layer. Malaria is profoundly climate-sensitive. Shifting rainfall, warmer temperatures, and extreme floods create ideal breeding conditions for mosquitoes.
A report by Boston Consulting Group and the Malaria Atlas Project in 2024 projects over half a million extra malaria deaths by mid-century due to climate change.
Conflicts from Sudan to Myanmar have displaced millions, collapsing health infrastructure and spreading infections across borders.
Fragile states, which house 16% of the world’s population, account for a third of all AIDS-related, TB, and malaria deaths. The convergence of these forces threatens not only health goals but also global security.
Communities as the backbone
What holds the system together in the face of such headwinds?
Communities. Community health workers remain the backbone of epidemic control. In 2024 alone, Global Fund investments trained more than 70,000 community health workers and 68,000 other health professionals.
They are trusted neighbours, educators, and advocates.
In Ethiopia, Fanose Hirreno’s two decades of service as a health extension worker have likely contributed to shifting norms, helping women claim ownership over their health.
In Sudan, amid active conflict, mobilisers like Rowida Briema still distribute malaria nets and medicines, often at great personal risk.
Communities are also innovators.
In southern Africa, young women supported by the HER Voice Fund shape national HIV policies to better reflect their realities. These are not beneficiaries; they are leaders.
Alongside people, infrastructure investments extend resilience.
Upgraded labs in 85 countries, new digital supply chain platforms in Malawi and Angola, and expanded oxygen capacity in 50 countries are not just disease-specific tools. They are multipurpose assets for pandemic preparedness. When COVID-19 struck, Global Fund-backed systems pivoted to deliver tests, treatments, and protective gear. The same laboratories that diagnose TB today may detect the next novel virus tomorrow.
A strategic choice
Sceptics often dismiss global health financing as charity. But the evidence is clear: it is one of the best investments in security and prosperity governments can make.
Every dollar spent generates multiple dollars in return through healthier workforces, reduced strain on health systems, and expanded trade.
Thanks to market shaping and generic competition, the Global Fund has driven down the cost of standard first-line HIV treatment from over US$10,000 a year in the early 2000s to as little as US$35-45 today in many low- and middle-income countries.
Advanced purchase commitments and pooled procurement have driven down the cost of next-generation malaria nets and diagnostics.
The next frontier is domestic investment.
The Fund’s sustainability policies are pushing countries to increase co-financing by about 20% compared to the previous cycle. Debt-for-health swaps, blended finance mechanisms, and private sector partnerships are multiplying available resources.
The model is not about dependency; it is about partnership. But partnership requires reciprocity. As governments in the Global South take on greater responsibility, those in the Global North must resist retreat.
A choice of futures
The story of global health today is paradoxical: extraordinary progress shadowed by profound risk.
Seventy million lives have been saved, yet millions more hang in the balance.
Communities have demonstrated their capacity to lead, yet they remain vulnerable to the whims of geopolitics and the turbulence of climate. At its core, the choice is not about spreadsheets or pledges.
It is about whether the world values the dignity of people such as Shifawu Abdulkarim, the quiet weavers of hope who stand between fragile communities and preventable death.
We can retreat, allowing funding cuts, stigma, and climate shocks to undo a generation of progress. Or we can reaffirm a truth proven again and again: that when communities are empowered, and when investments are sustained, health becomes not a privilege of the few but a shared foundation of security and prosperity for all.
The gathering storm is real. But so is the power of communities to weather it, if the world stands with them.
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Tian Johnson is the head of the African Alliance, a Pan-African civil society organisation advocating for equity, accountability, and community-led global health governance.
The views expressed in this opinion piece are those of the authors, who are not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.
