Growing attention to health challenges, particularly those facing low- and middle-income countries, has led to the emergence of new global institutions over time, especially in the past twenty-five years. Today, the global health architecture includes a number of diverse international organizations with different mandates, governance models, financing structures, and operational approaches. At the same time, several of these organizations support the same countries, address similar health issues, and rely on the same set of revenue sources. As such, questions have been raised about whether there is duplication and/or opportunity for synergies and better coordination across entities. These questions have become even more acute as fiscal environments have increasingly tightened. As a result, multiple reform efforts have been launched to explore these questions. As one input into these processes, KFF has developed a descriptive mapping of 14 key global health and related international institutions, with a focus on their work to address health challenges in low- and middle-income countries. By looking across a range of variables, it is intended to inform discussions about synergies and coordination, duplication, comparative advantage, shared challenges, and architectural reform. Key findings include (also see Table 1):

1. Organizational and governance models vary significantly, with implications for stakeholder representation that are particularly salient for civil society and affected communities. Among the 14 institutions, there is a range of organizational and governance models, with a fundamental distinction between the public-private partnerships and the member-state entities, most notably in their level of formal stakeholder representation and decision-making powers with public-private partnerships including multiple stakeholders while member-state organizations including only sovereign nations. This is particularly salient for formal civil society inclusion, which is a feature of the  public-private partnerships but absent from member-state organizations.
2. The 14 organizations address a range of health issues as a core part of what they do, with the most common being “health systems strengthening” (HSS).  After HSS, the second most common areas are global health security/pandemic preparedness and response (GHS/PPR) and maternal and child health (MCH), with less concentrated focus on disease-specific issues, and the least focus on family planning/reproductive health (FP/RH). As such, HSS may offer an opportunity for further collaboration and exploration, some of which is already underway.  
3. The primary functional modalities used – how each organization addresses health – vary as well, with the most common being technical assistance (TA) followed by country financing and market shaping.  Further assessment could identify opportunities for collaboration or streamlining across functional modalities, such as exploration of the types of TA provided, country financing models used, and whether there are additional areas of synergy across market shaping activities. 
4. Fundraising approaches and cycles are generally not aligned.  Most of the organizations included have different approaches to fundraising, including replenishment conferences and/or other investment opportunities, usually operating on different timelines. On the one hand, this may afford each organization the opportunity to draw focused attention to its efforts. On the other, donors may be faced with multiple successive investment opportunities at times when resources are tight.
5. For the subset of organizations that provide country financing, funding cycles are also not aligned. Instead, these periods are generally tied to organizational fundraising cycles – or in some cases, the type of financing instrument provided– presenting countries with multiple different grant and other financing periods, which in and of itself could contribute to inefficiency and administrative burden. 
6. Multiple graduation policies and co-financing requirements, while used to incentivize domestic spending and program transitions, could present countries with unanticipated and undue burden, at least in the short term. As resources tighten, and organizations are faced with the need to channel limited resources to the lowest income, highest need countries, an increasing number of countries are finding themselves on a glidepath to transition, including from more than one organization included in this analysis as well as other donors. As such, even countries with rising income may find themselves facing significant financial burden and challenges in taking over more of their health responses. How international organizations and others coordinate in this area could have significant implications for program sustainability.
7. Finally, while examination within any one variable yields important comparative information, a deeper dive across two or more provides a more comprehensive and nuanced picture of the role of each organization in the global health ecosystem. When viewed this way, the overlap between organizations is reduced and in some cases quite limited, such as for HIV, where the four organizations with an HIV focus do so from relatively distinct vantage points, with the Global Fund being the only one providing dedicated country financing. Similarly for FP/RH and vaccines, only one organization provides dedicated country financing (GFF for FP/RH and Gavi for vaccines). At the same time, for other areas, including HSS, and some functions, such as TA and market shaping, there is more overlap, including at times in the same set of countries.

Growing attention to health challenges, particularly those facing low- and middle-income countries, has led to the emergence of new global institutions, especially in the past twenty-five years. Today, the global health architecture includes a number of diverse international organizations with different mandates, governance models, financing structures, and operational approaches. At the same time, several of these organizations support the same countries, address similar health issues, and rely on the same set of revenue sources. As such, questions have been raised about whether there is duplication and/or opportunity for synergies and better coordination across entities. These questions have become even more acute as fiscal environments have increasingly tightened, and many international institutions have been forced to scale back operations. As a result, multiple reform efforts, including the Lusaka Agenda, the Accra Reset, the WHO’s Joint Process on Reform of the Global Health Architecture, and others,^1,2 have been launched to explore these questions.

As reform efforts intensify, the global health community has identified the importance of developing a more structured mapping across institutions (and efforts are underway to do so, including by the Multilateral Organization Performance Assessment Network (MOPAN)³). As another input into these processes, KFF has developed a descriptive mapping of 14 key global health and related international institutions, with a focus on their work to address health challenges in low- and middle-income countries (LMICs). By looking across a range of variables, it is intended to inform discussions about synergies and coordination, duplication, comparative advantage, shared challenges, and architectural reform, although it is not meant to represent an assessment of organizational performance or effectiveness. More broadly, any mapping of the global health institutional ecosystem, including this one, offers only a snapshot within what is a rapidly changing environment.

Fourteen international organizations were identified for inclusion (see Table 2). These organizations were chosen because they represent the main health-specific international organizations operating today or are international organizations that include health in their broader mandates or activities. Still, this list is not meant to be exhaustive and does not include all international organizations working in this space (and does not include donor government development agencies, philanthropic organizations, domestic governments, or regional development banks).

A key set of analytic domains and questions was identified for analysis (e.g., type of organization; governance structure; health focus areas; functional modalities/services; country funding, eligibility criteria, and others) as were indicators within each. To identify data and information for each indicator, a review of official organizational documents and other relevant materials was conducted, as was outreach to organizations as needed. In addition to looking within domains, the analysis also sought to look across several domains to better understand the role of each organization. It is important to note that the analysis is limited to the health focus areas and functional modalities selected for inclusion (based on their role in the current global health ecosystem). As such, they do not necessarily reflect the full scope of each organization’s activities. More detail on how information was identified and categorized is provided in the methodology. An appendix table provides detailed information by organization.

Organizational Classification

The 14 international organizations included in this analysis represent a range of different types of institutions, including United Nations member-based entities as well as independent, public-private partnerships, and multilateral development banks (MDBs⁴) (see Table 3).

• The independent and hosted⁵ public-private organizations all include multi-stakeholder representatives as part of their governance models, based on a variety of factors for inclusion (see more below). The UN and MDB institutions are member-state based organizations, most of which engage non-state actors to varying degrees, but without formal decision-making power (see below).
• The three independent public-private partnerships were each created outside of and as independent from the UN system, with independent governance bodies, rules, structures, and operations.
• The hosted public-private organizations are not legally separate entities from their hosts, and must follow certain of their policies and procedures, but range in their degree of independence in other areas. The GFF, as a World Bank “Multi-Donor Trust Fund” (MDTF), is required to have a “Trust Fund Committee” governance body, chaired by the World Bank, which acts as its main decision-making body.⁶ At the same time, it also operates as a global partnership with a separate governance body that functions in an advisory capacity and is comprised of a diverse group of stakeholders (see below). The Pandemic Fund, also hosted at the World Bank, is a “Financial Intermediary Fund” (FIF), an arrangement in which the Bank is a limited Trustee that administers the Fund and houses the organization but its governance is independent.⁷ RBM and Stop TB are each hosted by UNOPS which provides administrative and hosting services but they maintain independent governance and programmatic responsibility⁸; this is similar for Unitaid, hosted by WHO.⁹
• The organizations range in their longevity, with all but one of the UN and MDB entities having been established more than 50 years ago, while the independent and hosted public-private entities were created more recently, including three within the past 15 years.

Mission

Their missions range from more narrowly focused remits on specific health issues to much broader missions and goals (see Table 4). Of the 14, eight organizations have more focused missions – this is the case for all the independent and hosted public-private entities, each of which was created to address specific health challenges that have largely arisen or been recognized over the past two to three decades. The missions of the UN and MDB entities are generally broadly framed around expansive health and/or development goals and wider platforms that address multiple issues across all member states. One exception is UNAIDS which was created specifically to address HIV, which remains the focus of its mission.

Health as Primary Focus

Most, but not all, have “health” as their primary focus while others may include health in their work but it is not their main priority. Based on their stated missions and goals, eleven of the 14 institutions have health as their primary focus and as such are oriented around one or more specific health issues (see “health areas” below). The exceptions are UNICEF, IBRD and IDA which include health as part of their broader work (IBRD and IDA as part of the World Bank) and support health efforts but are not health-specific institutions. UNICEF, for example, works broadly to protect the rights of children, including through promoting health, but it also works on early childhood development, economic and social policy, and education. The World Bank has several strategic priorities, including health, as part of its larger mission to promote broader economic development and poverty reduction.¹⁰   

Governance Model

Governance models vary by size, stakeholder representation, and other characteristics, but generally fall into two overarching models – member-state and multi-stakeholder based (see Table 5). Within each model, there are different types of formal representation, and in some cases weights, given to board member seats. In the “member-state” model, the board or main governing entity is comprised of sovereign states only (IDA and IBRD apportion voting weights to member states based in part on financial contributions¹¹) with no formal voting power given to other stakeholders. In the multi-stakeholder model, the board or main governing entity is comprised of a range of types of stakeholders (e.g., sovereign donors, implementers/country recipients, area experts, civil society, and others), based on organizational mission, financial contributions, functional needs, and other factors. In some cases, a board seat is held by one entity (typically, a sovereign donor based on financial contributions) and in others, it is shared with several others (such as a board seat held by multiple country members, NGOs, or private sector organizations). There are variations in representation across institutions both in the type of stakeholders included as well as the number of seats given to them. For example, while all multi-stakeholder organizations except one (CEPI) have seats for implementing countries (those that receive support from the organization), the Global Fund’s Board includes seven implementing country members, two of which are from Africa (representing different parts of the continent) whereas the Pandemic Fund’s Board has nine implementing country members, four of which are from Africa. There is also wide variety in civil society representation.  

Civil Society Representation

One area of difference is the extent to which civil society and affected populations are represented (see Table 6). Eight entities (all the public-private organizations) have at least one civil society voting member on their governance body. Across these, the number of voting seats ranges from one each at Gavi and CEPI, to three at the Global Fund, and seven at Stop TB. Stop TB also has the greatest share of civil society voting seats on its board (27%), followed by the Global Fund (15%). None of the UN or MDB organizations provide voting rights to civil society, although UNAIDS is unique among them for having five non-voting civil society seats. In some cases, organizations also provide financial support to enable civil society, and implementer country, participation in Board and other governance meetings, including the Global Fund¹² and Unitaid¹³, while Stop TB indicates that it will try to support participation if funding permits.¹⁴

Decision-Making Procedures

Decision-making and voting procedures also vary, though most strive for consensus-based decisions, usually with specific voting rules if consensus cannot be reached (see Table 7).  Across the 14, nine organizations have a stated goal in their bylaws or other governance documents of reaching consensus-based decisions (including all of the independent or hosted public/private organizations except CEPI, and two UN entities – UNAIDS and UNFPA). If consensus cannot be reached, or, in the case of entities that do not use consensus, each organization specifies voting procedures. Six require a two-thirds supermajority and six a simple majority for decisions to pass. The Global Fund and the Pandemic Fund are unique in that each requires a two-thirds supermajority among each of their two voting blocs (donors and implementers); this procedure effectively allows for a minority of board members to prevent a decision from moving forward. Most of the consensus-based organizations, however, rarely take formal votes. An exception is the Global Fund which, while striving for consensus, formally records votes for each decision.

Voluntary/Assessed Contributions

All organizations but one rely on voluntary contributions to carry out their missions. Voluntary contributions, primarily from sovereign donors but also, in some cases, philanthropy, are the main revenue source for all but the IBRD. The IBRD borrows from international capital markets, secured with capital provided by member states, to provide loans to eligible countries. The WHO is unique among the 14 institutions in that it also relies on assessed contributions¹⁵ from member-states primarily based on country income (although assessed contributions make up a relatively small share of its revenue). There are other revenue sources for some organizations as well, such as Product RED, a consumer marketing initiative to finance HIV through the Global Fund¹⁶ and a voluntary airline ticket levy put in place by several governments to support Unitaid’s work.¹⁷ More generally, most of the organizations in this analysis rely on the same sources for funding, and most of their funding comes from a small number of donors. For example, 74% of the GFF’s contributions come from five donors (Norway, Canada, the Gates Foundation, the U.K., and the Netherlands)¹⁸ as do 68% percent of the Global Fund’s contributions (the United States, France, UK, Germany and Japan)¹⁹ and 73% of the Pandemic Fund’s contributions (the United States, EU, Germany, Italy, and Japan).²⁰

Strategic Periods/Replenishment

Eight of the 14 organizations use specific strategic periods and fundraising cycles, including “replenishment” models with pledging moments, to help mobilize multi-year commitments from donors (see Table 8). These include replenishment conferences or similar models used by six organizations – Gavi, GFF, the Global Fund, the Pandemic Fund, and IDA, as well as the recently instituted “Investment Round” by the WHO. CEPI and UNITAID don’t use replenishment models but also have investment cycles seeking multi-year commitments. These replenishment or fundraising cycles vary across organizations with the Global Fund using a three-year period while Gavi, CEPI, the Pandemic Fund, GFF, and UNITAID use five-year periods. Historically, IDA has used three-year periods but in its most recent replenishment, moved to a four-year period. The WHO’s newly instituted “Investment Round” was also for a four-year period. In general, these cycles do not align across institutions.

Country and Regional Operations

Seven organizations have country and regional operational offices, in addition to their global headquarters. All of the UN and MDB entities have country and regional operational offices, in addition to their headquarters based in Geneva, New York, or Washington DC.  None of the public-private organizations, which have headquarters in Geneva, Norway, or Washington DC, have country or regional operational offices²¹ and generally rely on the UN and MDB country-level operations to support their work in various capacities. While different than organizational country presence, the GFF has “Country Coordinators” and plans to expand their role, and its in-country presence more broadly, as part of its next strategy.²² The Global Fund requires there to be “Country Coordinating Mechanisms” (CCMs), which are national committees made up of government, NGO, and other stakeholders that submit funding applications and oversee grants on behalf of their countries.²³

Health Focus Areas

Within health, core or priority “focus” areas vary across institutions, with the most common being health systems strengthening (see Tables 9-10). Other organizations may contribute to, or support, these health areas but they are not a main or central focus. Among the seven health focus areas assessed [HIV, tuberculosis (TB), malaria, maternal and child health (MCH), family planning and reproductive health (FP/RH), health systems strengthening (HSS), and global health security/pandemic preparedness and response (GHS/PPR)]:

• Ten of the 14 organizations include a focus on health system strengthening (see Table 10). HSS is itself a broad set of activities²⁴ and each organization may be addressing similar areas (e.g., health workforce, supply chains) but in different ways. For example, Gavi’s support is for strengthening immunization infrastructure and services while the Global Fund is focused on strengthening HIV, TB, and malaria service delivery and systems.   
• The next two largest areas were each a focus of six organizations: MCH and GHS/PPR.
  • The six organizations working on MCH include: Gavi, with its core mission to scale up childhood immunizations; GFF, with a goal of ending preventable deaths of women, children and adolescents by mobilizing investments to improve country health systems; and Unitaid, which invests in innovative products designed to improve women and children’s health and reduce mortality. MCH is also a main focus for both UNICEF and UNFPA and one of WHO’s health areas.
  • Six organizations also include a core focus on GHS/PPR including two – CEPI and the Pandemic Fund – that were each created for this purpose which remains their core focus. The others, which include GHS/PPR as part of their other health work, are: Gavi, which coordinated and administered the COVAX Facility (for COVID-19 vaccines) during the COVID-19 pandemic and currently maintains the global strategic stockpiles for several outbreak-related vaccines; Unitaid which works to address capacity issues for future responses, and helps to respond to current outbreaks with new innovations;²⁵ the Global Fund which mobilized a COVID-19 response mechanism during the pandemic and, in its last strategy, added PPR as an evolving objective and currently supports outbreak response; and WHO which provides global coordination during outbreaks, monitors the response, seeks emergency funding through coordinated appeals, and develops standards and other guidance.²⁶
• Five organizations focus on malaria including: Gavi’s support for scaling up new malaria vaccines; the Global Fund’s support for malaria diagnostics, treatments, vector control, and other prevention and case management interventions; RBM’s advocacy and coordination; Unitaid’s work on new technologies and innovation; and WHO’s development of normative guidance and surveillance and other related data.
• Four organizations include a core focus on HIV – the Global Fund, Unitaid, UNAIDS, and WHO. Four include a core focus on TB – the Global Fund, Stop TB, Unitaid, and WHO. Other organizations, particularly Gavi, would step in once a vaccine for either HIV or TB, was available.
• The area with the least core focus is FP/RH, with just two organizations – GFF and UNFPA – having a decided focus and one – WHO – which includes FP/RH as one of the many health areas within its portfolio. 

Functional Modalities

Functional modalities/services – how organizations carry out their missions – also differ across organizations, with the most common function being technical assistance (TA), followed by country financing and market shaping activities (see Table 11). Among the six functional modalities assessed (country financing; normative technical guidance; technical assistance; market shaping/pooled procurement; research and development; and global health surveillance):

• The most common was technical assistance, which is both carried out directly and/or funded as a main function by nine of the 14 organizations. Several UN agencies – UNAIDS, UNICEF, UNFPA and WHO – and the GFF, RBM, and Stop TB directly provide TA support while the Global Fund and Gavi fund these same (and other) technical partners to provide TA in carrying out country-level supported activities.
• Six organizations provide country financing directly or through intermediaries including Gavi, GFF, the Global Fund, the Pandemic Fund, IBRD, and IDA. There are generally two types of financing instruments (with blended options in some cases): grants (non-repayable), which are provided by Gavi, GFF, the Global Fund, Pandemic Fund, and IDA, and loans (concessional – loans offered at below market rates, and non-concessional – loans offered at standard market rates) provided by IBRD and IDA. All but one (IBRD) of these six organizations raises and pools resources that are in turn allocated to countries based on specific criteria (see more information below).    
• Six organizations carry out market shaping – which includes a broad suite of activities to promote innovation, accelerate and scale-up new products such as strengthening regulatory institutions, supply chain activities, including pooled procurement, and market forecasting. These are: Gavi, the Global Fund, Stop TB via the Global Drug Facility (GDF), Unitaid, UNICEF and UNFPA. All but Unitaid operate pooled procurement³⁷ mechanisms for a variety of health products (see Table 12), some of which have various arrangements between them to make products available. For example, Gavi procures most of its vaccines from UNICEF, and the Global Fund procures most TB products from GDF. GDF, UNICEF, and UNFPA health products are available to all countries, while Gavi and the Global Fund only allow current, and in some cases, formerly, eligible countries to access products. GDF, UNICEF, and UNFPA each offer pre-financing lines of credit to address liquidity and other constraints that can prevent countries from procuring commodities, and the Global Fund is planning to institute such an instrument.
• Normative guidance is provided by four organizations, led by WHO but also including UNAIDS, UNICEF, and UNFPA, often in conjunction with the WHO. Guidance developed by the UN system is in turn used by the other institutions to guide and support their work, including informing the development of operational and programmatic guidance.
• Similarly, global health surveillance and monitoring is also carried out by four organizations, all UN entities – WHO, UNAIDS, UNICEF, and UNFPA – and these data are in turn used by several of the other organizations in a variety of ways, including for developing operational and programmatic guidance, determining eligibility for funding and levels of support, and for measuring progress. The GFF has begun to move into this area, recently launching “FASTR” to provide “Rapid-Cycle Analytics for Data Use” as an alternative to in-person household and facility-based surveys, though not at the global level.³⁸ Importantly, while Gavi and the Global Fund also fund efforts to strengthen data collection and surveillance at the country level, global health surveillance is not in and of itself a core modality.
• Just one institution – CEPI – conducts R&D for health. It focuses on developing vaccines and countermeasures to address epidemic and pandemic threats. While R&D isn’t a major WHO function, it serves to coordinate R&D networks and efforts and provide technical resources. In addition, Unitaid carries out some aspects of late-stage R&D and other areas of research on a limited basis.

Civil Society and Key Populations

One notable difference across organizations is the extent to which they actively fund civil society organizations (CSOs) and/or focus efforts to reach key and vulnerable populations. In addition to including civil society in governance, a subset of organizations also includes specific funding streams or mechanisms to support CSO involvement in country-level programming and monitoring. Gavi, for example, as part of its “Civil Society and Community Engagement (CSCE)”, requires countries to allocate at least 10% of country cash budget funding ceilings³⁹ to CSOs for implementation. The Global Fund was founded on a principle of partnership with CSOs and communities and, in addition to being part of CCMs, CSOs manage Global Fund grants as principal and sub-recipients; between 2017-2022, the Global Fund reports that CSOs managed $9.25 billion, or 30%, of country funding.⁴⁰ In addition, the Global Fund supports community-led monitoring to assist with tracking program implementation and identifying access barriers.⁴¹ GFF also supports CSO and youth engagement including in developing country investment cases and working to advocate for increased financing for health priorities.⁴²  Stop TB has a “Challenge Facility for Civil Society” (CFCS) which provides grants to CSOs to engage in national TB responses.⁴³  In addition to these efforts, some organizations include a specific focus on reaching those most at risk, including populations that may not be served by country governments. This is particularly the case for the Global Fund which focuses on key and vulnerable populations affected by HIV, TB, and malaria to increase access to services.⁴⁴  Several other organizations include key and vulnerable populations in their work, including Stop TB, RBM, and UNAIDS.

Country Eligibility and Funding Allocation

All six of the organizations that provide country financing (or financing institutions) use country income, and in some cases other criteria, for determining eligibility to receive funding (see Table 13). Gavi, the GFF, the Global Fund, the Pandemic Fund, IBRD, and IDA all use country income (the World Bank’s Atlas Method) for determining eligibility. Some use additional criteria, combined with income. For example, while all low- income and lower middle-income countries are eligible for Global Fund support for HIV, TB, and malaria, upper middle-income countries are only eligible if they meet additional requirements by disease. For the Pandemic Fund, while all IDA and IBRD countries were initially eligible, only countries that have not yet received support have been eligible for subsequent funding rounds.⁴⁵  In addition, the most recent funding round added new eligibility criteria to focus on countries with the greatest capacity gaps, highest pandemic risks, and significant socioeconomic challenges. The GFF also uses other factors to determine eligibility, including risk of overall debt distress and epidemiological burden specific to maternal and child health. IBRD limits eligibility to middle-income countries as well as “creditworthy” low-income countries. The Global Fund and Gavi also use country income to determine the level of co-financing required and graduation timelines (see below).

While the number of countries eligible for financing across these six organizations varies, a subset receives support from all or most of the six (see Tables 14-15 and Appendix Table). Based on current eligibility criteria, there are 148 countries that are eligible for funding across the six organizations. The Global Fund has the greatest number of eligible countries (123), followed by IBRD (86) and IDA (78). Fifty-six countries are eligible for Gavi and the GFF, respectively, while 15 are eligible for the Pandemic Fund’s most recent funding round.⁴⁶ Across all six, there are 31 countries eligible to receive funding from four institutions, 20 from five institutions, and two from all six. All countries eligible for Gavi, the GFF, and the Pandemic Fund are also eligible for Global Fund support (for at least one disease component). GFF and Gavi overlap in 52 countries and Pandemic Fund eligible countries are also eligible for Gavi and GFF. Future changes to country eligibility, as more countries transition out of eligibility, will likely change this picture, potentially in significant ways (see graduation policy below).

Five of the six financing organizations also use specific methodologies to allocate funds to eligible countries, driven by limited grant resources (see Table 16). Three organizations – Gavi, the Global Fund, and the Pandemic Fund – use methodologies that channel funding to the lowest income and highest need countries, including recent modifications to do so even further. In the case of Gavi and the Global Fund, this approach, coupled with co-financing and graduation policies (described below), serves to drive funding to the countries with the greatest needs. The GFF does not specify an allocation formula, but bases funding decisions on country investment cases. IDA uses an index with multiple factors for allocating resources to countries.

Grant Cycles

The six financing organizations generally have different approaches to country-level grant or funding cycles, with minimal alignment. This is due primarily to two factors: different fundraising/replenishment periods and different types of funding instruments. Gavi uses a 5-year grant cycle, tied to its 5-year replenishment cycle. The Global Fund and Pandemic Fund also tie their grant cycles to their replenishment periods, but these are for 3-year periods. The GFF provides grants on a rolling basis, with different multi-year periods depending on the country investment case (typically three to five years) but also leverages this funding within broader IBRD and IDA financing instruments, which in turn operate differently.^53,54 IDA grants are for different multi-year periods (generally, three to five years)⁵⁵ while IDA credit and loan instruments and IBRD loans mature over much longer periods, including decades, depending on the instrument.⁵⁶  

Scale of Country-Level Support

Among the financing institutions⁵⁷, the level of financial support for health efforts in countries varies significantly (see Table 17). The Global Fund is largest followed by IDA, Gavi, IBRD and GFF (see Table). Of note, IDA and IBRD amounts listed below include funding leveraged by the GFF. The Pandemic Fund’s country financing is smallest among this group, though it is three times greater than the GFF’s grant component. More broadly, IBRD and IDA support, which is mostly provided in the form of loans (with just 24% of overall IDA financing provided as grants⁵⁸) is also quite different in nature from the grant-making of the other institutions.

Graduation Policies

Gavi, the Global Fund, and IDA each have formal graduation policies⁵⁹ after which countries are generally no longer eligible for support, although several others have transitioned countries from support. Such policies are increasingly used as resources tighten and organizations move to channel limited resources to those most in need and promote sustainable programs in others. The criteria used are largely defined by income level, although other factors may be used, and the approaches generally span several years (so countries don’t face an unexpected funding cliff).

• For Gavi, once a country has been in its last phase of eligibility (the accelerated transition phase) for eight years, it is no longer eligible for Gavi support. To date, 19 countries have graduated from Gavi support, two of which recently re-gained Gavi-eligibility. Seven countries are currently in the last phase of eligibility.
• For the Global Fund, once a country reaches upper middle-income status, it is no longer eligible for funding if it does not meet any disease component requirements. At this point, it may receive one additional allocation of transition funding (three years) for that component. To date, 52 disease components across 38 countries have transitioned from eligibility, and in the current grant cycle (GC7), 12 disease components from eight countries are transitioning.⁶⁰ At the end of the next grant cycle (GC8), 35 countries (as well as several others that receive funding through multi-country grants) will transition from country allocations.⁶¹
• For IDA, once a country reaches an IDA-defined operational cut-off level, there are three phases of graduation to IBRD-only financing which also include assessments of creditworthiness.
• For IBRD, a graduation threshold is based on income, at which point, other factors may be considered for determining whether eligibility could continue.
• While the GFF does not have a specific graduation policy, countries have been “phased out” of funding eligibility due to their progress in meeting health milestones. As mentioned above, subsequent funding rounds of the Pandemic Fund have not been open to countries that have already received support.

Co-Financing Policies

Gavi and the Global Fund are unique in requiring country co-financing as a condition of receipt of financial support, although other institutions encourage, incentivize, or otherwise have mechanisms to support country co-financing. Both Gavi and the Global Fund have had long-standing co-financing requirements which are scaled based on country income capacity (with waivers allowed in exceptional circumstances):

• For Gavi, countries are required to share in the cost of vaccine procurement for routine vaccination (and for use in one-time immunization campaigns and periodic follow-up campaigns).  The amount of co-financing varies by country income and transition status from Gavi eligibility with countries required to provide a portion of the cost of each vaccine dose, working towards 100% country-financed.
• For the Global Fund, all countries are required to co-finance their grants with variation by country income level. For example, low income and lower middle-income countries are required to demonstrate progressive government expenditure on health, while upper middle-income countries are required to focus 100% of their co-financing on specific sustainability and transition priorities. All must progressively co-finance the costs of key programmatic interventions and of national HIV, TB, and malaria responses and/or health systems strengthening though the size of the increase is scaled by country income.
• Several other institutions include co-financing as a strategic objective. For example, the Pandemic Fund has an overall goal of achieving a portfolio-wide leverage ratio of 1:4 – for every US$1 provided by the Pandemic Fund, US$4 is mobilized from country sources and applications for support are scored in part on a country’s co-financing commitment. The GFF supports country health financing reform, including country efforts to enable and incentivize increased domestic investments in health. UNFPA, through its Supplies Partnership has a co-financing “matching fund” model for a subset of 54 countries whereby for every dollar a government spends on reproductive health commodities (whether purchased from UNFPA or another procurement entity), UNFPA matches with $2 from the UNFPA Supplies Partnership.⁶² The 54 countries eligible for this are chosen based on their GNI per capita, modern contraceptive prevalence rate (mCPR), and maternal mortality rate (MMR). UNICEF Supplies also has similar matching programs, including its “Maternal, Newborn, and Child Health Match Fund” that matches 1:1 for every dollar a government spends on commodities.⁶³

Multidimensional Analysis

Finally, analysis across multiple dimensions provides a more nuanced picture of the role of each organization in the global health ecosystem. While an examination of organizations within a discreet area, such as health focus, functional modality, or country eligibility, yields important comparative information, a fuller examination across two or more of these variables provides a more comprehensive and nuanced look at where organizations might overlap or play more distinct roles. For example, when viewed this way:

• The overlap between organizations is reduced and in some cases quite limited. For example, the organizations with a core focus on HIV do so from relatively distinct vantage points – Unitaid focuses on upstream product innovation and introduction, the Global Fund focuses on downstream scale up as the main funder of programs and services, including commodities, and UNAIDS and WHO provide guidance, TA, and global surveillance data to support their efforts. For malaria, Unitaid similarly focuses on upstream product innovation and introduction, the Global Fund on downstream service scale up for treatment, prevention, and diagnosis, Gavi on the malaria vaccine, and RBM and WHO provide guidance, TA, and data. For GHS/PPR, CEPI focuses on R&D, particularly at earlier stages, Unitaid picks up innovation and introduction, Gavi maintains the stockpile for outbreaks, and the Pandemic Fund funds countries to prepare and strengthen systems. In several cases, there is only one organization providing dedicated country financing for a particular health area or product, including Gavi for vaccines, GFF for MCH and FP/RH, and the Global Fund for HIV, TB, and malaria.
• This is less clear, however, for HSS, the most common health focus area across organizations. While each addresses HSS through its own lens (e.g., Gavi is focused on strengthening immunization infrastructure, the Global Fund on strengthening HIV, TB, and malaria systems, GFF on strengthening systems to delivery MCH programs and services, and WHO on providing coordination and support), many of the supported HSS activities are similar, such as health workforce, facilities, supply chains, financing reform.
• Among the six financing organizations, there is significant overlap in countries reached, although the scale of financing and its focus vary significantly. For example, the Global Fund is the only one of the six providing financing specifically for HIV, TB, and malaria treatment and prevention, and Gavi is the only one of the six providing vaccines. But both organizations also support HSS in many of the same countries, as do several of the other financing organizations.  

This analysis can help to identify areas for potential coordination and cooperation, as well as comparative advantage, and point to where additional information may be useful. Broad themes and observations include the following:

1. Organizational and governance models vary significantly, with implications for stakeholder representation that are particularly salient for civil society. Among the 14 institutions, there is a range of organizational and governance models, with a fundamental distinction between public-private partnerships and member-state entities in their models, approaches, and governance. This is most notable in their level of formal stakeholder representation and decision-making powers, with the public-private partnerships including multiple stakeholders while member-state organizations only including sovereign nations. This is particularly salient for formal civil society voting participation, which is a feature of the public-private partnerships but absent from member-state organizations.
2. The 14 organizations address a range of health issues as a core part of what they do, with the most common being health systems strengthening. After HSS, the next most common areas are GHS/PPR and maternal and child health, with less concentrated focus on disease-specific issues, and the least focus on FP/RH. As such, HSS may offer an opportunity for further collaboration and exploration, some of which is already underway, including among Gavi, GFF, and the Global Fund⁶⁴ as well as between Gavi and the Global Fund.⁶⁵
3. The functional modalities used – how each organization addresses health – vary as well, with the most common being technical assistance followed by country financing and market shaping.  Further assessment could identify opportunities for collaboration or streamlining across functional modalities. For example, market shaping activities are carried out by six organizations, including five which operate pooled procurement. These five are already interdependent in some ways, and additional exploration – such as the extent to which they could coordinate on strengthening regional and country level procurement and supply chain systems – could identify areas of synergy.  
4. Fundraising approaches and cycles are generally not aligned, which may have benefits as well as challenges.  Most of the organizations included have different approaches to fundraising, including replenishment conferences and/or other investment opportunities, usually operating on different timelines. On the one hand, this may afford each organization the opportunity to draw focused attention to its efforts. On the other, donors may be faced with multiple successive investment opportunities at times when resources are tight.
5. As a result, for the subset of organizations that provide country financing, funding cycles are also not aligned. Instead, these periods are generally tied to organizational fundraising cycles – or in some cases, the type of financing instrument provided– presenting countries with multiple different grant and other financing periods which in and of itself could contribute to inefficiency and administrative burden.  
6. Multiple graduation policies and co-financing requirements, used to incentivize domestic spending and program transitions, could present countries with unanticipated or undue burden, at least in the short term. As resources tighten, and organizations are faced with the need to channel limited resources to the lowest income, highest need countries, an increasing number of countries are finding themselves on a glidepath to transition, including from more than one organization included in this analysis as well as other donors. As such, even countries with rising income may find themselves facing significant financial burden and challenges in taking over more of their health responses. How international organizations and others coordinate in this area could have significant implications for program sustainability.
7. Finally, while examination within any one variable (such as health focus area, functional modality, or country eligibility criteria) yields important comparative information, a deeper dive across two or more would provide a more comprehensive and nuanced picture of the role of each organization in the global health ecosystem. When viewed this way, the overlap between organizations is reduced and in some cases quite limited, such as for HIV, where the four organizations with an HIV focus do so from relatively distinct vantage points, with the Global Fund being the only one providing dedicated country financing. Similarly for FP/RH and vaccines, only one organization provides dedicated country financing (GFF for FP/RH and Gavi for vaccines). At the same time, as mentioned above, most organizations are focusing on HSS, there are several organizations engaged in market shaping, and many organizations are carrying out technical assistance activities, sometimes in the same set of countries.  

Fourteen international organizations were chosen for inclusion in this analysis: the Coalition for Epidemic Preparedness (CEPI); Gavi, the Vaccine Alliance (Gavi); the Global Finance Facility (GFF); the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); the Pandemic Fund; RBM Partnership (RBM); Stop TB Partnership (Stop TB); Unitaid; the Joint United Nations Programme on HIV/AIDS (UNAIDS); the United Nations Population Fund (UNFPA); the United Nations Children’s Fund (UNICEF); the World Health Organization (WHO); the World Bank, International Bank for Reconstruction and Development (IBRD); and the World Bank, International Development (IDA). These organizations were included because they represent the main health-specific international organizations operating today or are international organizations that include health in their broader mandates or activities. All of these organizations were included in a recent Accra Reset paper. Eleven were included in either the Reimagining the Future of Global Health Initiatives report commissioned by the Wellcome Trust or the World Health Organization’s effort to re-examine the global health architecture. Still, this list is not meant to be exhaustive and does not include all international organizations working in global health, donor government development agencies, philanthropic organizations, domestic governments, and regional development banks, among others.

A key set of analytic domains was identified for analysis:

1. Organizational classification (type of organization);
2. Mission;
3. Health as primary focus (whether health was primary focus of organization’s work or part or a larger mandate);
4. Governance model (including board representation, decision-making, and voting procedures);
5. Funding model (voluntary and/or assessed contributions or other sources; fundraising process);
6. Operational model (whether organization has country or regional operations);
7. Health focus areas (which areas of health are core to the organization’s mission or strategic objectives);
8. Functional modalities/services (the main ways in which health work is carried out);
9. Countries reached (for those organizations that provide country financing: eligibility criteria, allocation methodologies, geographic scope and overlap, grant cycles, graduation and co-financing policies).

To populate the indicators within each domain, a review of official organizational documents (governance documents, by-laws, charters, annual reports, strategic plans, financial statements, etc) was conducted, as was outreach to organizations as needed. 

Seven health areas were included for assessment: HIV, tuberculosis (TB), malaria, maternal and child health (MCH), family planning/reproductive health (FP/RH), health systems strengthening (HSS), and global health security/pandemic preparedness and response (GHS/PPR). Several of these health areas are overlapping and reinforcing – for example, efforts to strengthen health systems can feed into and bolster GHS/PPR and vice versa, and addressing malaria is a key component of improving child health. This list is not meant to be exhaustive, but, rather, to reflect the main health challenges that disproportionately face low- and middle-income countries; as such, these seven areas are captured by more than half of the Sustainable Development Goal 3 (SDG 3) targets on good health and well-being. For each, official organizational documents were reviewed to assess whether a particular health area was a core focus or, instead, something they may contribute or provide support to. For purposes of this analysis, the WHO, as the global health organization, was considered to have a core focus on all the areas measured, as they are part of its broad mandate.

Six functional modalities/services were included for assessment: country financing; normative guidance; technical assistance; market shaping/pooled procurement; research and development; and global health surveillance. These modalities were also identified in the Reimagining the Future of Global Health Initiatives report, as well as other initiatives. As with health areas, official documents were reviewed to assess whether it was a main modality of the organization.

• Table 1: Summary of Select Indicators
• Table 2: Organizations Included
• Table 3: Organizational Classification
• Table 4: Organizational Mission
• Table 5: Voting Members: Board Size and Composition
• Table 6: Civil Society Inclusion in Governance
• Table 7: Decision-Making Procedure
• Table 8: Strategy and Replenishment Periods
• Table 9: Health Focus Areas
• Table 10: Health Systems Strengthening
• Table 11: Major Functional Modalities/Services
• Table 12: Pooled Procurement Products
• Table 13: Country Eligibility Criteria Across Financing Institutions
• Table 14: Number of Eligible Countries by Financing Institution
• Table 15: Pairwise Overlap Across Financing Institutions (# of Countries Eligible for Both)
• Table 16: Country Funding Allocation Across Financing Institutions
• Table 17: Annual Health Funding to Countries (USD) by Financing Institution, 2025

The Appendix Table is available to read in full via PDF (download).

1. Reform efforts and processes include: The Future of Global Health Initiatives/Lusaka Agenda, https://futureofghis.org/; The Accra Reset, https://accrareset.org/; WHO Global Health Architecture Joint Reform Process, https://www.who.int/about/governance/global-health-architecture; Wellcome Trust, https://wellcome.org/insights/reports/rethinking-reform-way-forward-global-health-system?utm_source=linkedin&utm_medium=o-wellcome; EU and Like-minded Donors’ Reflection Process on Reform of the Global Health Architecture, https://www.hera.eu/news/hisp-report-reflection-process-reform-global-health-architecture; The MOPAN Study on the Comparative Advantage in the Multilateral Health Ecosystem, https://www.mopan.org/en/our-work/performance-insights/comparative-advantage-in-the-multilateral-global-health-ecosystem.html; and HEAR CSO, https://hearcso.org/. There have also been several analytic pieces on this subject, including: SSRN: https://ssrn.com/abstract=6753079. ↩︎
2. In addition to reform efforts, there have been several analytic pieces on this subject. See, for example: Witter, S., Palmer, N., Jouhaud, R. et al. Understanding the political economy of reforming global health initiatives – insights from global and country levels. Global Health 21, 40 (2025). https://doi.org/10.1186/s12992-025-01129-0; Grude, Sine and Pohl, Marionka and Musasizi, Joshua and Jackson Zikanga, Bernard and Foley, Brendan and Atuhaire, Roderick and Atuhairwe, Irene and Kerry, Vanessa Bradford, Navigating Global Health Architecture Reform Efforts – Between Reform and Fragmentation (May 12, 2026). http://dx.doi.org/10.2139/ssrn.6753079. Nishtar S, Global health leap: an urgent call to action, The Lancet, 2026; 407, 820-824. Mwisongo A, Nabyonga-Orem J. Global health initiatives in Africa – governance, priorities, harmonisation and alignment. BMC Health Serv Res. 2016 Jul 18;16 Suppl 4(Suppl 4):212. doi: 10.1186/s12913-016-1448-9. PMID: 27454542; PMCID: PMC4959383. ↩︎
3. MOPAN, Comparative Advantage in the Multilateral Health Ecosystem, https://www.mopan.org/en/our-work/performance-insights/comparative-advantage-in-the-multilateral-global-health-ecosystem.html. ↩︎
4. IDA and IBRD are technically specialized agencies of the United Nations but are still independent entities. See, Agreement Between the United Nations and The International Bank for Reconstruction and Development, 1947 and Agreement between the United Nations and the International Development Association, 1960. ↩︎
5.  Hosted partnerships are housed at another organization which provides varying levels of operational support. ↩︎
6. World Bank Group, “Guidance: Governance in World Bank Trust Funds”, https://thedocs.worldbank.org/en/doc/f75ed72705f93add074bcf2d729e4a82-0060072022/original/Governance-in-Trust-Funds.pdf. ↩︎
7. Pandemic Fund, Governance Framework, as amended, December 2025, https://www.thepandemicfund.org/sites/default/files/2026-02/Governance%20Framework.pdf. ↩︎
8. UNOPS, Hosted Partnerships, https://www.unops.org/hosted-partnerships. ↩︎
9. Unitaid, Constitution, July 2011, https://unitaid.org/uploads/EB14-R08-Unitaid-constitution.pdf. ↩︎
10. World Bank Group Annual Report 2025, https://www.worldbank.org/en/about/annual-report#anchor-annual. ↩︎
11. World Bank Group, Voting Powers, https://www.worldbank.org/en/about/leadership/votingpowers. ↩︎
12. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Constituency Funding Policy, December 2016, https://www.theglobalfund.org/media/2939/core_boardconstituencyfunding_policy_en.pdf. ↩︎
13. Unitaid, Board Operating Procedures, November 2019, https://unitaid.org/uploads/UNITAID_EB33_2019_8_Board-Operating-Procedures-Revised-21-November-2019-Adopted.pdf. ↩︎
14. Stop TB Partnership, Board Governance Manual, July 2023, https://www.stoptb.org/sites/default/files/documents/March%202025%20STBP%20Board%20Governance%20Manual.pdf. ↩︎
15. These are set amounts expected to be paid by member-state governments, scaled by income and population. ↩︎
16. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Partner Profiles, (RED), https://www.theglobalfund.org/en/private-sector-and-philanthropy/profiles/red/; (RED), https://www.red.org. ↩︎
17. Unitaid, Press Release, “Unitaid welcomes new air levy coalition, building on its legacy of successful innovative health financing”, July 2025, https://unitaid.org/news-blog/unitaid-welcomes-new-air-levy-coalition-building-on-its-legacy-of-successful-innovative-health-financing/. ↩︎
18. KFF analysis of data from the GFF, available at: https://www.globalfinancingfacility.org/partnership/donors (accessed July 2026). ↩︎
19. KFF analysis of data from the Global Fund to Fight AIDS, Tuberculosis and Malaria, available at: https://www.theglobalfund.org/en/government/ (accessed July 2026). ↩︎
20. KFF analysis of data from the Pandemic Fund, available at: https://www.thepandemicfund.org/contributors (accessed July 2026). ↩︎
21. Some, such as Gavi and CEPI, have administrative offices in other locations primarily to facilitate interactions with donor governments. ↩︎
22. The World Bank Group, GFF, Transform 2030: Transforming Health Systems, Saving Lives, Strategy, 2026-2030, December 2025, https://www.globalfinancingfacility.org/sites/default/files/GFF-Strategy-2026-2030/GFF-Strategy-2026-2030-Final-Edition-ENG-04Dec2025.pdf. ↩︎
23.  In addition to CCMs, there may also be Regional Coordinating Mechanisms (RCMs), and in certain cases, non-CCMs and Regional Organizations (RO). See, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Country Coordinating Mechanism Policy Including Principles and Requirements, May 2018,   https://www.theglobalfund.org/media/7421/ccm_countrycoordinatingmechanism_policy_en.pdf. ↩︎
24. The World Health Organization defines HSS as “initiatives and strategies that improve one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency, ensuring it can address health threats. A well-functioning health system is built on having trained and motivated health workers, a well-maintained infrastructure, and a reliable supply of medicines and technologies, appropriate service delivery approaches, backed by adequate funding, all these articulated in strong health plans and evidence-based policies.” See, https://www.afro.who.int/health-topics/health-systems-strengthening. ↩︎
25. See, for example, Unitaid, Press Release, “Unitaid launches investment package to accelerate access to promising Bundibugyo Ebola diagnostics and medicines”, July 2026, https://unitaid.org/news-blog/unitaid-launches-investment-package-to-accelerate-access-to-promising-bundibugyo-ebola-diagnostics-and-medicines/. ↩︎
26. WHO, Global health emergencies, https://www.who.int/emergencies/overview. ↩︎
27. Gavi, Health Systems and Immunisation Strengthening Policy, January 2023,  https://www.gavi.org/sites/default/files/about/governance/corporate-policies/07-Gavi-Health-Systems-and-Immunisation-Strengthening-Policy.pdf. ↩︎
28. GFF, Resilient Health Systems, https://www.globalfinancingfacility.org/focus-areas/resilient-health-systems. ↩︎
29. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Resilient and Sustainable Health and Community Systems, https://www.theglobalfund.org/en/resilient-sustainable-systems-for-health/. ↩︎
30. The Pandemic Fund, Strategic Plan (2024-2029), May 2024, https://www.thepandemicfund.org/sites/default/files/2025-12/Pandemic%20Fund%20Strategic%20Plan_12-15-25_0.pdf. ↩︎
31. Unitaid, Strategy, 2023-2027, https://unitaid.org/uploads/Unitaid_Strategy_2023-2027.pdf. ↩︎
32. UNFPA, The UNFPA Supplies Partnership, https://www.unfpa.org/unfpa-supplies-partnership. ↩︎
33. UNICEF, About Us, https://www.unicef.org/supply/about-us. ↩︎
34. WHO, Health Systems Governance, https://www.who.int/health-topics/health-systems-governance#tab=tab_2. ↩︎
35. The World Bank Group, Health Works, https://www.worldbank.org/ext/en/health-works. ↩︎
36. The World Bank Group, Health Works, https://www.worldbank.org/ext/en/health-works. ↩︎
37. Pooled procurement refers to the consolidation of demand across multiple buyers with the goal of obtaining lower prices, reduced transaction and administrative costs, streamlined quality assurance, and more predictable markets, to help improve better access. See, KFF, The America First Global Health Strategy and Pooled Procurement, January 2026,https://www.kff.org/global-health-policy/the-america-first-global-health-strategy-and-pooled-procurement/. ↩︎
38. GFF, FASTR, The GFF’s Initiative for Rapid Cycle Analytics and Data Use, https://data.gffportal.org/key-themes/FASTR. ↩︎
39. From combined HSS, Equity Accelerator Fund (EAF) and Targeted Country Assistance (TCA) ceiling funding amounts. See: Gavi, CSO Engagement Strategy, https://www.gavi.org/about-us/our-partners/civil-society#engagement.  ↩︎
40. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Civil Society, https://www.theglobalfund.org/en/civil-society/ and The Global Fund’s Funding for Community and Civil Society Organizations, An Analysis of Grant Cycle 5 and Grant Cycle 6, July 2024, https://www.theglobalfund.org/media/14830/cs_funding-community-civil-society-organizations_report_en.pdf. ↩︎
41. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Community Responses and Systems, https://www.theglobalfund.org/en/community-responses-and-systems/. ↩︎
42. GFF, CSOs and Youth, https://www.globalfinancingfacility.org/partnership/csos-youth. ↩︎
43. Stop TB Partnership, Challenge Facility for Civil Society, https://www.stoptb.org/what-we-do/supporting-communities-overcome-access-barriers/funding-people-affected-tb-and-local-communities. ↩︎
44. For HIV, key populations include men who have sex with men, trans and gender diverse people, sex workers, people who use and/or inject drugs, people living with HIV, people in prison and other closed settings. For TB, key populations include prisoners and incarcerated populations, people living with HIV, migrants, refugees, miners and indigenous populations. For malaria, these include refugees, migrants, pregnant women, children under 5, internally displaced people and indigenous populations in malaria-endemic areas. Vulnerable populations include adolescent girls and young women, people with disabilities, and others with increased vulnerabilities in particular contexts. See: The Global Fund to Fight AIDS, Tuberculosis and Malaria, Key Populations, https://www.theglobalfund.org/en/key-populations/. ↩︎
45. The Pandemic Fund, Call for Proposals, https://www.thepandemicfund.org/call-for-proposals ↩︎
46. More countries have been reached by organizations over time. For example, while 15 countries were eligible for funding through the Pandemic Fund’s most recently funding round, 128 countries have been funded to date. ↩︎
47. Gavi, 6.0 Funding Guidelines, April 2026, https://www.gavi.org/sites/default/files/support/guidelines-2026/gavi-60-funding-guidelines-annexes.pdf. ↩︎
48. Gavi, Review of Decisions, Board Meeting, December 2024, https://www.gavi.org/sites/default/files/board/minutes/2024/4-5-december/Board-2024-Mtg-03-Review%20of%20Decisions.pdf. ↩︎
49. GFF, What is the Process for Accessing the GFF Trust Fund?, https://www.globalfinancingfacility.org/what-process-accessing-gff-trust-fund. ↩︎
50. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Allocation Methodology For Grant Cycle 8, 52^nd Board Meeting, November 2024, https://archive.theglobalfund.org/media/15310/archive_bm52-08b-allocation-methodology-gc8_report_en.pdf. ↩︎
51. The Pandemic Fund, Guidance Note For Applicants of the Fourth Call to Proposals, April 1, 2026, https://www.thepandemicfund.org/sites/default/files/2026-04/4th%20CfP_Guidance%20Note.pdf; The Pandemic Fund, Risk-Need Metric and Methodology, January 2026, https://www.thepandemicfund.org/sites/default/files/2026-02/PF_Risk-Need%20Methodology%20Final%20Report%20-%20Final%20Jan22_0.pdf. ↩︎
52. The World Bank Group, IDA Resource Allocation Index (IRAI), June 2026, https://ida.worldbank.org/en/financing/resource-management/ida-resource-allocation-index. ↩︎
53. For example, Senegal’s investment case, which form the basis of grant requests, is for the 2024-2030 period, Kenya is for 2025/2026-2029/2030, and the Central African Republic is for 2024-2026. See, The GFF,  https://www.globalfinancingfacility.org/resources?keys=&knowledge_model%5B112%5D=112&viewsreference%5Bcompressed%5D=eJxdj8EKAyEMRP8lZw_t1V8pRVJMbUBT0XTLsuy_N-JB6CEkM_PmkAMiKoK_3R2Q4CNTDJ1UWVIHfwC29CkkCn6dDpQ1k1lznw4qNkuCDesedK8jNRNTw_qCf4CjxddlP5lyDIJl1KbYmL4LaLRx57es5qRYqYRIebxwOX9caEjN. ↩︎
54. GFF, Guidance Note, Investment Cases, https://www.globalfinancingfacility.org/resource/guidance-note-investment-cases.   ↩︎
55. The World Bank Group, Projects Database, https://projects.worldbank.org/en/projects-operations/projects-list?prodline_exact=PE&projectfinancialtype_exact=Grants&os=0&sector_exact=FY17%20-%20Health. ↩︎
56. The World Bank Group, IDA Financial Products, https://treasury.worldbank.org/en/about/unit/treasury/ida-financial-products; The World Bank Group, IDA Lending Terms, https://ida.worldbank.org/en/financing/ida-lending-terms; The World Bank Group, IBRD Financial Products, https://treasury.worldbank.org/en/about/unit/treasury/ibrd-financial-products/financial-products-faqs. ↩︎
57. It is important to note that several other institutions included in this analysis (UNAIDS, UNICEF, UNFPA, and WHO) report some level of official development assistance to the OECD DAC. However, because they are not financing institutions, as defined in this analysis, they were not included in this section. ↩︎
58. The World Bank Group, IDA Financing, https://ida.worldbank.org/en/financing. ↩︎
59. Also see, KFF, Future Reform of PEPFAR: Exploring the Use of a Graduation Policy, April 2025, https://www.kff.org/global-health-policy/future-reform-of-pepfar-exploring-the-use-of-a-graduation-policy. ↩︎
60. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Sustainability, Transition and Co-Financing,https://www.theglobalfund.org/en/sustainability-transition-and-co-financing. ↩︎
61. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Transition Timelines, April 2026, The Global Fund to Fight AIDS, Tuberculosis and Malaria, https://www.theglobalfund.org/media/hvkncr4j/cr_gc8-transition-timelines_list_en.pdf; Eligibility, Allocations & Funding,https://archive.theglobalfund.org/en/eligibility-allocations/. ↩︎
62. UNFPA, Annual Report, 2025, https://www.unfpa.org/sites/default/files/pub-pdf/UNFPA%20Supplies%20Partnership%20Annual%20Report%202025_30June2026_Final.pdf. ↩︎
63. UNICEF, Supply Strategy, 2026-2029, https://www.unicef.org/supply/media/24836/file/UNICEF-Supply-Strategy-2026-2029.pdf. ↩︎
64. GFF, GFF, Gavi and Global Fund Collaboration, Investors Group Meeting, November 2025, https://www.globalfinancingfacility.org/sites/default/files/IG21/GFF-IG21-4-EN-3-GHI-Collaboration.pdf. ↩︎
65. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi-Global Fund Collaboration Update 54th Board Meeting, February 2026, https://archive.theglobalfund.org/media/2ojoitpc/archive_bm54-10-gavi-global-fund-collaboration_update_en.pdf. ↩︎

Key Takeaways

• LGBTQ+ adults face significantly greater challenges accessing and affording health care compared to their non-LGBTQ+ peers. They are more likely to postpone or skip needed care (58% vs. 38%), forgo prescription medications due to cost (22% vs. 12%), and struggle to pay medical bills (30% vs. 21%).
• Cost-related barriers to care are especially pronounced among certain segments of the LGBTQ+ population, most notably trans adults, younger LGBTQ+ adults, those with lower incomes, and those without health coverage. Eight in ten (82%) trans adults, three-quarters (77%) of LGBTQ+ adults without health coverage, and two-thirds (68%) of those under age 30 report not getting needed health care in the past 12 months either because they couldn’t get an appointment, couldn’t afford the cost, or for another reason. Additionally, larger shares of LGBQ+ women than men report skipping or delaying care in the past year (63% vs. 46%).
• While trans adults represent a small share of the total LGBTQ+ population, they experience outsized barriers to affording care and other access issues. Compared with other LGBQ+ groups, trans adults report the highest rates of difficulty finding providers with available appointments (53%), not taking prescription medications because of cost (39%), worsening health from postponed care (45%), struggling with medical bills (42%), and experiencing insurance delays or denials (61%). Trans adults experience these greater barriers to health cost and access even when controlling for other demographic variables such as age, income, and insurance status.
• Health care costs create significant financial strain for many LGBTQ+ adults. Three in ten (30%) report problems paying medical bills in the past year, and one in five (19%) say they cut back on household necessities such as food or clothing to pay for health care costs. Financial burdens are particularly common among younger adults, those with lower incomes, and those without health coverage.
• Having health insurance does not guarantee timely access to care. About three in ten LGBTQ+ insured adults report that their insurance delayed or denied coverage for recommended care in the past two years, a more widespread experience than among non-LGBTQ+ insured adults, with particularly high rates among trans adults and those covered by Medicaid or those with ACA marketplace coverage.

Understanding the Challenges LGBTQ+ Adults Face Affording Health Care

LGBTQ+ adults in the U.S. are a growing population who have historically faced health disparities in terms of both wellbeing and health care access and affordability. Previous research has found that LGBTQ+ adults are more likely than their non-LGBTQ+ peers to experience barriers to obtaining needed care, to struggle to afford health care costs, and to delay or forgo care because of cost. These affordability challenges often intersect with and may even be a driver of broader health disparities, including poorer mental and physical health outcomes, particularly among trans adults.

Understanding the financial challenges LGBTQ+ adults face when accessing health care can help identify persistent gaps in affordability and inform efforts to improve access to needed care and coverage.

Delays in Health Care for LGBTQ+ Adults

Six in ten LGBTQ+ adults (58%) say they have skipped or postponed needed health care in the past year, greater shares than their non-LGBTQ+ counterparts (38%). This includes more than four in ten (43%) LGBTQ+ adults who say they’ve skipped or delayed getting needed care because of the cost and about three in ten who said it was due to their inability to get an appointment (28%) or for some other reason (29%). LGBTQ+ adults are nearly twice as likely as non-LGBTQ+ adults (26%) to say they’ve skipped or delayed getting needed care because of the costs.

Compared to other LGBQ+ adults, trans adults are more likely to report they have put off care in the past year because of cost or other issues (82%). At least half of trans adults say they skipped or postponed getting needed health care because of the cost (56%), because they couldn’t find a doctor or health care provider with appointments available (53%), or they skipped or postponed for any other reasons (48%). There may be many reasons why trans adults are more likely to skip or delay care, but a recent KFF/Washington Post Trans Survey found significant barriers for trans adults in getting needed health care, including providers not being properly educated to provide appropriate care.

Beyond trans adults, larger shares of LGBQ+ women than men report skipping or postponing care in the past year (63% vs. 46%). This includes half of LGBQ+ women who say they skipped or postponed needed care because of the cost (compared to a third of LGBQ+ men), and roughly a third of LGBQ+ women who say they skipped or postponed care because they couldn’t get an appointment (31% vs. 19% of LGBQ+ men) or for any reason besides cost or not being able to get an appointment (32% vs. 21% of LGBQ+ men). Across all LGBTQ+ groups, non-LGBTQ+ adults less commonly reported skipping or postponing care.  

Many socioeconomic and demographic factors can predict delaying or skipping care, but LGBTQ+ adults are more likely to skip or delay care even when controlling for race and ethnicity, insurance coverage, age, income, and education, suggesting this population group may have unique struggles in accessing needed health care. The differences reported in this analysis between LGBTQ+ adults and non-LGBTQ+ adults hold even when controlling for these demographic characteristics.

Among all LGBTQ+ adults, two-thirds (68%) of those under age 30 report having put off needed care in the past year, higher than the shares of older LGBTQ+ adults who report this. While age is a significant predictor of putting off care regardless of sexual identity, LGBTQ+ adults under age 30 are twenty percentage points more likely to report putting off care than non-LGBTQ+ adults in the same age range (48%). In fact, across most age groups, LGBTQ+ adults are more likely to report putting off or postponing needed care than their non-LGBTQ+ counterparts, except for those 65 and older. The difference between LGBTQ+ and non-LGBTQ+ adults levels out among those age 65 and older, which may be due to several factors, such as increased medical care among older adults and Medicare eligibility.

Insurance and income also play a role in accessing care. Three in four (77%) LGBTQ+ adults without health insurance report having missed or delayed care in the past year for any reason, compared to six in ten LGBTQ+ adults with health insurance. Fewer non-LGBTQ+ adults than LGBTQ+ adults without health insurance report experiencing any of the following in the past year (65% vs. 77% of uninsured LGBTQ+ adults).

Similarly, about six in ten LGBTQ+ adults with household incomes under $40,000 a year (59%) or between $40,000 and $99,999 a year (63%) say they skipped or postponed needed care, compared to half of those with annual incomes of $100,000 or more. Even among the highest income groups or those with health insurance, LGBTQ+ adults are more likely than non-LGBTQ+ adults to say they skipped or delayed needed care in the past year.

Substantial shares of LGBTQ+ adults report postponing their care worsened their health, and that number is especially pronounced among trans adults. Three in ten (29%) LGBTQ+ adults say their health got worse because they skipped or delayed care, which is about twice the share of non-LGBTQ+ adults who report the same (14%). This experience is more common among LGBQ+ women (34%) than LGBQ+ men (20%). Almost half (45%) of trans adults say they delayed or skipped care and their health got worse as a result.

The share who say their health got worse due to postponing care also rises to roughly a third of uninsured LGBTQ+ adults (35%) and those under age 30 (35%). One-third (33%) of LGBTQ+ adults with household incomes of less than $40,000 report that their health got worse because of postponed care.

Impacts of Cost on Prescription Medications

Cost barriers also affect prescription medication behavior, including among LGBTQ+ adults, with about a fifth of LGBTQ+ adults (22%) saying they’ve cut pills in half, skipped doses of a medication, or decided not to fill a prescription because they couldn’t afford the cost (compared to 12% of non-LGBTQ+ adults). Trans adults (39%), LGBTQ+ adults without insurance (28%), LGBQ+ women (25%), and younger LGBTQ+ adults (23% of those under age 30), are the most likely to report that they didn’t take their prescription medication as prescribed due to cost.

In addition, around a quarter of LGBTQ+ adults with lower incomes report cutting pills in half, skipping doses of medications, or not filling a prescription in the past year due to cost, including 27% of those with a household income of less than $40,000 a year, and 24% of those with incomes between $40,000 and $99,999 a year, compared to around one in ten (12%) of LGBTQ+ adults with incomes of $100,000 or more a year.

Difficulty Paying Medical Bills

Substantial shares of LGBTQ+ adults also report struggling with medical bills. Three in ten LGBTQ+ adults say they have had problems paying for or were unable to pay a medical bill, including bills for doctors, tests or labs, or medication in the past 12 months, higher than the 21% of non-LGBTQ+ adults who say the same. This includes four in ten (42%) trans adults, over a third (36%) of LGBQ+ women and two in ten (21%) LGBQ+ men.

Problems with bills can lead to important financial consequences for many LGBTQ+ adults. Two in ten (19%) LGBTQ+ adults, including two in ten (22%) LGBQ+ women and roughly one in ten (13%) LGBQ+ men say they’ve had to cut back on household expenses like food, clothing, or other basic household items in order to pay for health care costs. This experience is more common among trans adults, over one quarter of whom (28%) report the same. Overall, LGBTQ+ adults report they have cut back on necessities to pay for health care costs more commonly than non-LGBTQ+ adults (13%).

Younger LGBTQ+ adults and those with lower household incomes, two groups with considerable overlap, are among the most likely to report problems paying medical bills in the past year, with around a third of those under age 30 (33%), between 30 and 49 (34%), those with incomes of less than $40,000 a year (35%) or between $40,000 and $99,999 (35%) reporting they had problems paying or an inability to pay for any medical bills in the past year. Individuals earning over $100,000 annually and those 65 and older, who are largely covered by Medicare, are less likely to report such problems.

Younger LGBTQ+ adults and those with lower incomes are also more likely to report cutting back on expenses because of their problems paying medical bills. Overall, a quarter (24%) of LGBTQ+ adults with household incomes less than $40,000 a year say they have cut back on household expenses like food, clothing or other basic household items to pay for health care costs, compared to two in ten (19%) LGBTQ+ adults with incomes between $40,000 and $99,999 and one in ten (11%) of those with incomes of $100,000 or more a year.

Younger LGBTQ+ adults are also more likely to report cutting back on expenses because of trouble paying medical bills, including two in ten LGBTQ+ adults under age 30 and between ages 30 to 49 (21% for each) compared to one in ten (13%) LGBTQ+ adults ages 50 to 64 and one in twelve (8%) of those ages 65 and older.

Insurance Delays or Denials

Treatments or medications recommended by a provider may be delayed, and in some cases, an insurance company may deny coverage for the recommended medication or treatment after or during the care process. While insurance coverage helps some LGBTQ+ adults deal with access and cost issues, many face other challenges such as delayed or denied care.

Roughly one-third of insured LGBTQ+ adults say their insurance company denied coverage (32%) or delayed (30%) their ability to get a health care service, treatment, or medication that their doctor prescribed in the past two years. Four in ten say coverage has either been delayed or denied. These shares are substantially higher than among non-LGBTQ+ adults, about a quarter (26%) of whom say they’ve experienced a denial of service (21%) or delay (17%) in the past two years.

These experiences are particularly common among trans adults, roughly six in ten (61%) of whom say they’ve been delayed (53%) or denied (45%) coverage by their insurance for a service, treatment, or medication prescribed by their doctor in the past two years.

Delays and denials of coverage for LGBTQ+ adults vary based on what type of insurance they have. Individuals with either self-purchased plans or Medicaid report experiencing these most often. Roughly half (48%) of LGBTQ+ adults under age 65 who have Medicaid (48%) or self-purchased insurance (46%) say their insurance company has denied or delayed health care services, treatments, or medications in the past two years. Given that Medicaid plays a larger role in covering LGBTQ+ people, this coverage difference may in partially explain some of the disparate challenges this group faces with delays and denials.  

Roughly four in ten (39%) LGBTQ+ adults under age 65 with employer-sponsored insurance say the same while just three in ten (28%) LGBTQ+ adults ages 65 and older with Medicare report experiencing recent delays and denials.

The share of LGBTQ+ adults with various types of health insurance who report delays or denials of needed care is larger than the share of non-LGBTQ+ adults who say the same. Roughly a third of those non-LGBTQ+ adults with Medicaid (33%) or self-purchased insurance (31%), around a quarter (26%) of those with employer-sponsored coverage, and around two in ten (18%) of non-LGBTQ+ adults who have Medicare and are ages 65 or older report these issues.

The KFF Survey of Health Status and Caregiving was a series of questions designed and implemented by KFF with the SSRS Opinion Panel Mega-Omnibus. The survey was conducted May 4 – May 26, 2026, online and by telephone among a nationally representative sample of 25,873 U.S. adults in English (n=25,422) and in Spanish (n=451).

The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) recruited via random digit dial (RDD) telephone sample of cell phone numbers connected to a prepaid cell phone. Both samples were provided by Marketing Systems Group (MSG). The combined sample was reached either online (n=24,875) or over the phone (n=998) based on the panelist’s stated preference. For the online panel component, invitations were sent to panel members by email followed by up to four reminder emails and up to two reminder text messages (if consented to receive SMS).

The questions designed by KFF were included as part of a multi-stakeholder effort designed to survey all individuals currently empaneled in the SSRS Opinion Panel, with each organization paying for and having independent editorial control over its survey questions.  Substantive questions from other outside stakeholders are redacted in this report. The SSRS survey team designed the questionnaire in order to minimize potential bias from question ordering. For more information, please contact SSRS.

Respondents who completed on the web received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). Respondents who completed the survey on the phone received $10 via a physical check in the mail. In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 10% item non-response, or (3) had a length of less than 30% of the mean length by mode. Based on this criterion, 69 cases were removed.

Data were weighted to represent adults 18+ in the United States. The Panel-wide base weight adjusts for the SSRS Opinion Panel recruitment and retention process. Because all current panelists (except 2026 recruits) were invited to participate and no further sampling was performed, no further adjustments to the Panel-wide base weight were necessary before applying it to the survey data.

With the Panel-wide base weight applied, the survey-data were weighted to match the sample’s demographic profile to the same target population parameters used in the calibration of the entire SSRS Opinion Panel. The demographic variables included in weighting for the general population sample are gender, age, race/ethnicity, and education (including interactions between these categories), as well as region, civic engagement, density, frequency of internet use, voter registration, political party identification, religion, household makeup, and home ownership. Final calibrated weights are trimmed at the 2^nd and 98^th percentiles to prevent individual interviews from having too much influence.

The margin of sampling error including the design effect for the full sample is plus or minus 1 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available on request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.