For decades, the architecture of global health has been built on an asymmetrical relationship between donor and recipient countries, often mirroring the colonial structures that shaped the world’s economic and political order. The traditional model of foreign aid — where wealthier nations dictate health priorities, channel funding through large international organisations, and impose external solutions on lower- and middle-income countries (LMICs) — has led to dependency rather than self-reliance. Today, the movement to decolonise global health is challenging these dynamics, advocating for a shift from aid-driven models to sustainable, equitable partnerships that empower LMICs to take charge of their own health systems.

The legacy of colonialism in global health is deeply ingrained. Many health systems in Africa, Asia, and Latin America were originally designed to serve colonial administrations, with a focus on disease control and the protection of colonial economies rather than the holistic well-being of indigenous populations. Even after independence, these structures persisted, with newly formed governments inheriting underfunded and fragmented health systems that remained reliant on external support. This reliance was further cemented by the emergence of international aid organisations that took on the role of providing healthcare where national systems were weak.

The post-war era saw the rise of major global health institutions — the World Health Organisation (WHO), the World Bank, and later, the Global Fund and GAVI — each playing a critical role in financing and shaping health policy in LMICs. However, their governance structures, funding mechanisms, and decision-making processes have often reinforced a top-down approach. Policies are frequently designed in Geneva, New York, or London, then implemented in countries with little input from the communities they are meant to serve. This has resulted in a model where LMICs are passive recipients rather than active architects of their own health strategies.

The traditional donor-recipient model is flawed in several ways. First, it creates a power imbalance where donors control funding flows, set priorities, and demand accountability on their terms. This often means that funding is directed towards high-visibility, short-term projects — such as disease-specific vertical programs for malaria, HIV/AIDS, and tuberculosis — rather than comprehensive health system strengthening. As a result, recipient countries are often left with parallel, externally driven health initiatives that are not well integrated into national strategies. Second, the financial sustainability of this model is questionable. Many LMICs remain heavily dependent on donor funding for essential health services. In some countries, foreign aid accounts for over 50% of health expenditures. However, donor priorities are fickle, often shifting due to geopolitical events, economic downturns, or changes in political leadership in donor countries. The recent reallocation of global health funding to pandemic preparedness and conflict-related humanitarian crises has left many essential health programs in LMICs underfunded. Third, the dominance of international NGOs and development agencies has stifled local capacity building. Many of these organisations operate with expatriate leadership, sidelining local expertise and reinforcing a cycle of dependency. This dynamic not only marginalises national health institutions but also diverts talent away from government services, as local professionals are often recruited into better-paying NGO roles.

Despite these challenges, LMICs are increasingly taking charge of their health policies, challenging the dominance of Western-led global health governance. This shift is evident in several areas: The African Union’s Africa Centres for Disease Control and Prevention (Africa CDC) and ASEAN’s health initiatives have strengthened regional preparedness and cooperation, while countries like Rwanda and Thailand have successfully implemented universal health coverage (UHC) schemes, reducing reliance on external funding. The COVID-19 pandemic exposed LMICs’ vulnerabilities in vaccine access, prompting initiatives like South Africa’s Aspen Pharmacare and Senegal’s Institut Pasteur to establish local manufacturing capabilities, reducing dependency on Western pharmaceutical companies. Simultaneously, there is growing momentum to shift global health research from a Eurocentric model to one that prioritises local expertise, with initiatives like the African Academy of Sciences and India’s National Institute of Epidemiology driving research agendas that reflect local health priorities rather than donor-driven interests.

To truly decolonise global health, the international community must move beyond rhetoric and implement structural reforms that empower LMICs. This requires a fundamental shift in the way global health partnerships are conceived and operationalised.

1. Redefining Aid as Investment in National Health Systems
   • Donor funding should prioritise health system strengthening rather than vertical, disease-specific programs.
   • Financing mechanisms should be restructured to allow for greater flexibility and long-term sustainability, reducing dependency on external funds.
2. Shifting Decision-Making Power to LMICs
   • International health institutions must include more representation from LMICs in leadership and governance structures.
   • National health ministries should take the lead in setting research priorities and health policies, with international organisations playing a supporting role rather than dictating terms.
3. Supporting Regional Health Integration
   • Strengthening regional bodies like Africa CDC, PAHO, and ASEAN’s health initiatives can enhance collective bargaining power and self-reliance.
   • Cross-border health collaborations should be encouraged, including pooled procurement of medicines and joint disease surveillance programs.
4. Investing in Local Manufacturing and Supply Chains
   • International funding should support LMIC-led pharmaceutical production, reducing reliance on Western imports.
   • Technology transfer agreements should be expanded, enabling LMICs to develop their own medical research and innovation hubs.
5. Decolonising Global Health Education and Research
   • Funding agencies must prioritise grants for researchers based in LMICs, rather than channelling resources through Western institutions.
   • Global health curricula should be restructured to incorporate perspectives from LMICs, ensuring that knowledge production is not solely Western-centric.

The movement to decolonise global health is not about rejecting international cooperation but rather redefining it. The goal is to move from a system of dependency and external control to one based on genuine, equitable partnerships. By shifting decision-making power, investing in local health systems, and supporting homegrown innovation, LMICs can chart their own health futures. The process will not be easy, as entrenched interests resist change, but the alternative — continuing a system that perpetuates inequality and inefficiency — is no longer acceptable.