In the global health arena, Africa stands at a paradoxical crossroads. Despite bearing a disproportionate share of the burden from diseases such as AIDS, tuberculosis, and malaria, the continent remains severely underrepresented in the decision-making bodies that govern the allocation and distribution of critical health funds. This disparity is laid bare in a landmark article published on 15 September 2025 in BMJ Global Health, which advocates for increasing African governmental representation on the governing board of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The research, spearheaded by experts affiliated with Supporting Health Initiatives (SHI) at Wits University, argues persuasively that enhancing African voting power is not only a matter of justice but also a strategic imperative for improving global health outcomes.
Currently, Africa receives nearly three-quarters—71%—of the GFATM’s funding, a clear reflection of the continent’s immense health challenges and needs. However, this funding disparity is coupled with a meager 10% holding in voting rights on the Fund’s governing board. Such a skewed distribution of influence disrupts the equilibrium necessary for an accountable, responsive, and context-sensitive global health governance structure. As the article unfolds, it becomes clear that augmenting Africa’s representation by even a single governmental voting seat would yield substantive reforms. This is consistent with principles outlined in the Paris Declaration on Aid Effectiveness and other international frameworks urging more inclusive and equitable governance in global aid institutions.
The importance of this issue extends beyond mere symbolism. Enhanced African representation would directly impact the sustainability and efficacy of health interventions by aligning funding decisions with local realities and priorities. Robyn Hayes-Badenhorst, co-executive director of SHI and a co-author of the BMJ article, highlights how systemic minimization of African voices undermines the continent’s health sovereignty. She calls for a comprehensive overhaul of global health institutional architecture, moving beyond incremental governance changes to fundamentally redefining power balances that currently marginalize those most affected by global health policy decisions.
The urgency for reform is underscored by a recent funding crisis within the GFATM. In July 2025, the Fund announced a startling cut of US$1.43 billion from its current funding cycle, precipitated in part by the US government’s freeze and subsequent dismantling of USAID, along with further reductions in funding commitments from key donors such as Germany. This funding contraction threatens longstanding programs and exacerbates uncertainties, especially in African countries reliant on these resources. The cuts add a new layer of complexity to an already fragile health financing ecosystem, amplifying calls for more equitable governance structures that can navigate and mitigate such shocks.
In this climate of fiscal volatility, experts view the current crisis as a strategic inflection point. Professor Garrett Wallace Brown from the University of Leeds, who led the SHI research, frames the moment as a “window of opportunity” for radical reform within global health governance. He advocates for more representative strategic investments that promote African self-reliance, thereby reducing dependency on unstable external funding. The argument centers not only on increasing voting seats but also on recalibrating institutional focus towards sustainable domestic health financing and capacity building.
Domestic financing is spotlighted as an indispensable pillar of Africa’s health future. The continent’s persistent reliance on external aid hampers the development of robust local health systems capable of enduring shocks. However, domestic financing does not exist in isolation; it is intimately linked to the dynamics of global health governance and decision-making. Africa’s ability to mobilize resources internally is deeply influenced by the architecture of institutions like GFATM. As Magda Robalo, formerly chair of the Ethics and Governance Committee of the Global Fund, notes, meaningful reforms require not only shifts in representation but also enhanced technical, administrative, and leadership capacity within African states.
Despite the breadth of African health challenges spanning 47 countries, the continent is currently allocated only two voting seats on the GFATM board—one representing Eastern and Southern Africa, and one for Western and Central Africa. This arrangement dilutes the effectiveness of governance by forcing representatives to cover vast regions with diverse epidemiological, sociopolitical, and infrastructural contexts. Increasing the number of African governmental seats would alleviate this burden, enabling more focused advocacy and nuanced policy development that responds to region-specific needs. Dr. Lieve Fransen, a founding chair of the GFATM board, emphasizes that while adding one seat may appear incremental, such governance changes accumulate significant impact over time.
The BMJ Global Health article is bolstered by a complementary report coordinated by SHI, which presents empirical data underscoring the benefits of enhanced African involvement in global health governance. This research demonstrates a positive correlation between increased representation and improved ownership, contextualization, and aid sustainability. These factors collectively enhance aid effectiveness by ensuring that programs are aligned with the cultural, economic, and health system realities of recipient countries, thereby fostering more durable health outcomes.
Fundamental reforms must also address the accountability dynamics between donors and recipient states. Raising domestic funding is essential, as established by the Abuja Declaration’s target of allocating 15% of national budgets to health. Unfortunately, only a few African countries consistently meet this benchmark, limiting the pool of available resources and constraining the potential for co-financing arrangements that incentivize mutually beneficial donor-recipient partnerships. Additionally, just 57% of GFATM funds flow through public systems, a shortcoming that impedes effective capacity building and undermines health system strengthening efforts vital for long-term sustainability.
The article highlights that donors increasingly expect transparency, efficiency, and ownership from recipient countries, particularly as the global health funding environment becomes more precarious. Greater African representation on the GFATM board is viewed as a critical mechanism to future-proof the institution against external shocks and shifting donor priorities. Professor Brown asserts that reforms enhancing Africa-first governance are not only ethically necessary but are also pragmatic strategies to safeguard the enduring functionality of global health financing mechanisms.
The timing of this publication and accompanying report is particularly strategic. Released shortly before the G20 summit in South Africa, these works aim to influence global leaders as they deliberate commitments to promote inclusive governance and build resilient health systems. The ongoing debate around African representation is emblematic of broader questions related to equitable power sharing in international institutions, issues that resonate deeply in the context of post-pandemic health system recovery and reform worldwide.
Advocates like Hayes-Badenhorst emphasize the critical need for a loud and united African voice at forums like the G20 to press for the addition of at least one governmental voting seat on the GFATM board. Such an expansion is anticipated not merely as a procedural adjustment but as a foundational step toward establishing more just, responsive, and sustainable health governance architectures. Empowering African governments through stronger representation will enhance the alignment of health policies with local realities, encourage program longevity, and reduce chronic dependency on external aid actors.
This discourse on governance reform exemplifies a broader paradigm shift in global health, moving from top-down aid delivery toward participatory, equitable frameworks that acknowledge and address historical imbalances. Increasing African representation at decision-making tables is central to this transformation, potentially charting a course toward a more inclusive and effective global health system capable of meeting 21st-century challenges with resilience and shared responsibility.
Subject of Research: African representation and governance reforms in global health institutions, specifically the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Article Title: It is time to increase Africa’s governmental representation on the governing board of the global fund to fight AIDS, tuberculosis and malaria
News Publication Date: 15 September 2025
Web References:
https://gh.bmj.com/content/10/9/e018252
http://dx.doi.org/10.1136/bmjgh-2024-018252
Keywords: Public policy, Health care, Health equity, Geographic regions
Tags: African health governanceAIDS tuberculosis malaria fundingenhancing African voting powerequitable health resource allocationGlobal Fund decision-makingglobal health equityglobal health representationgovernmental representation in healthhealth funding disparitieshealth outcomes in Africastrategic health imperativesSupporting Health Initiatives Wits University
