Fifty-four million child deaths averted among children under five since 2000: this figure, whose order of magnitude is documented by major UN agencies, is the most spectacular result of a quarter century of massive investments in global health. It deserves to be read for what it is: one of the most significant collective achievements in human history. It also deserves to be read in context: since 2015, progress has slowed, several indicators have declined, and the financial model that made all this possible is decomposing.

This is not a collapse. It is something more difficult to articulate: gains that hold but whose momentum is exhausting. The WHO report poses a question that few commentators have relayed: can victories built on international aid be preserved when that aid withdraws?

The Essentials

  • HIV infections have declined by 40% between 2010 and 2024; child mortality under five has fallen by 51% since 2000; maternal mortality has decreased by 40% over the same period.
  • Since 2015, the pace of progress has slowed on nearly all major indicators, and several have declined in low-income countries.
  • The withdrawal of external funding, particularly from the United States, directly threatens the programs that produced these results.
  • Non-communicable diseases are advancing in middle-income countries and now constitute the principal global health challenge, without benefiting from a financing framework comparable to that built for infectious diseases.

Three Victories That Deserve to Be Named

The WHO report opens with data that would be wrong to read too quickly. In 2000, 9.8 million children under five died annually worldwide. In 2024, this figure drops to 4.8 million. This is a 51% reduction in twenty-five years, achieved through a documented combination of factors: vaccination, access to clean water, malaria control, nutrition, and management of respiratory diseases.

On HIV, the progression is of the same order. Forty percent fewer infections between 2010 and 2024. The PEPFAR program, funded by the United States since 2003, has much to do with this: it has enabled more than 20 million people to be placed on antiretroviral treatment in sub-Saharan Africa. UNAIDS estimated in 2023 that PEPFAR had saved 25 million lives. This is not a metaphor: it is a public program that reorganized entire health systems across a continent.

Maternal mortality, finally, has declined by 40% since 2000. In 2000, the global maternal mortality ratio was 328 deaths per 100,000 live births—approximately 443,000 maternal deaths that year total—; in 2023, this ratio was 197 deaths per 100,000 live births. Again, specific actors enabled this result: the United Nations Population Fund (UNFPA), coalitions of NGOs such as Family Care International, and national public policies in countries like Ethiopia, Rwanda, and Bangladesh, which massively invested in births assisted by qualified personnel.

These three victories have a common point: they are the product of deliberate investments, not spontaneous improvement. This is precisely what makes them vulnerable.

The Mechanics of Slowdown Since 2015

The positive data hide an inflection that the WHO report documents unambiguously. Since 2015, the pace of progress has slowed on nearly all indicators. On maternal mortality, the Sustainable Development Goals target for 2030 is 70 deaths per 100,000 live births. The world is at 197. It would need to divide this figure by approximately 2.8 in a few years. At the current pace, this will not happen.

This slowdown is not a homogeneous phenomenon. In high-income countries, indicators continue to progress, sometimes slowly, sometimes rapidly thanks to therapeutic innovations. It is in low-income countries that momentum most clearly runs out, and in some cases reverses. The report notably cites the resurgence of vaccine-preventable diseases in contexts where supply chains have been disrupted by economic crises or conflicts.

What is at stake here is not simply a question of pace. It is a question of mechanism. The progress of the 2000s was built on a specific model: high-income countries finance vertical programs (dedicated to a particular disease or issue), international organizations coordinate them, and local governments gradually integrate them into their health systems. This model worked. But it also created dependencies. When external funding withdraws, local systems are not always able to take over.

Non-Communicable Diseases, the Challenge Without a Program

There is an angle in the WHO report that press summaries have almost unanimously ignored. Non-communicable diseases, diabetes, cardiovascular diseases, cancers, chronic respiratory diseases, are now the leading cause of mortality in middle-income countries. They are advancing. And they benefit from no international financing framework comparable to what has been built for HIV, malaria, or tuberculosis.

The comparison is instructive. The Global Fund to Fight AIDS, Tuberculosis and Malaria has mobilized more than 65 billion dollars since its creation in 2002, according to its own reports. For non-communicable diseases, there is no equivalent. The reason lies partly in the nature of these diseases: they are multifactorial, their management is costly and long-term, and they relate to questions of lifestyle and consumption that international aid actors have historically been reluctant to address, particularly in the face of agribusiness and tobacco industries.

The result is an imbalance documented by the WHO: tools exist to treat infectious diseases, as do financing mechanisms. For chronic diseases, neither is equal to the challenge. In a country like Mexico, where type 2 diabetes affects nearly 15% of the adult population according to PAHO (Pan American Health Organization), this gap has direct consequences for the burden on public hospital systems.

The American Withdrawal and Its Concrete Effects

In 2025, the American administration announced massive cuts to international health aid, directly affecting PEPFAR, WHO financing, and contributions to the Global Fund. The exact amounts vary depending on sources and budget arbitrations still underway, but the order of magnitude is considerable: the United States represented 42% of total international health aid in 2023, and approximately a third of Global Fund contributions alone.

The question is not abstract. It translates into concrete figures in specific countries. In Zambia, Uganda, Mozambique, programs preventing mother-to-child HIV transmission operate in large part thanks to PEPFAR funding. An interruption, even partial, of this funding does not produce a gradual slowdown: it creates supply chain ruptures that can quickly translate into resurgences of infections.

The WHO report does not directly name the United States, but its director-general Tedros Adhanom Ghebreyesus has been explicit in his public statements since early 2025: the withdrawal of major donors creates a real threat to the gains of the last twenty years. Other actors are attempting to compensate. France has maintained its contributions to the Global Fund. Germany has announced strengthened participation. The Gates Foundation continues to invest massively in vaccination programs, notably through GAVI, the Vaccine Alliance. But the geography of international health financing is being redistributed under conditions of emergency, not planning.

It is necessary here to be precise about what these financings concretely produce. These are not humanitarian expenditures without return. A study by the Copenhagen Consensus Center estimated in 2023 that each dollar invested in child health in low-income countries generated approximately 45 dollars in long-term economic benefits, accounting for life-years gained and increased productivity. These estimates are subject to legitimate methodological debates, but they signal that the question of global health financing is inseparable from questions of economic development that other articles in this journal have documented.

Local Health Systems, Unfinished Business

The true structural lesson of the WHO report is not the HIV or child mortality figure. It is what it says, implicitly, about the fragility of health systems in low- and middle-income countries. Twenty-five years of massive investments made it possible to treat specific diseases. They did not always make it possible to build systems capable of functioning autonomously.

This diagnosis is not new. It has been posed for at least ten years by health economists like Dani Rodrik or institutions like the Brookings Institution. But it becomes particularly acute at the moment when external funding is withdrawing. A health system that depends on 40% of international aid to finance its healthcare workers is not a system that can absorb a financing shock without damage.

A few countries have succeeded in making progress on this front. Rwanda is often cited as an example, and for documented reasons: since 2005, the country has developed a health mutual system, the Mutuelle de Santé, which covers more than 90% of the population according to the Rwandan Ministry of Health. This system is not perfect, and its results are the subject of nuanced analyses in academic literature, but it represents a model of endogenous financing that reduces dependence on external aid.

Ethiopia followed a comparable trajectory by deploying on a large scale an army of community health workers, the Health Extension Workers, who played a central role in reducing child and maternal mortality. These workers are paid by the Ethiopian government, not by NGOs. It is precisely this type of integration that is lacking in many countries where international aid bypassed public systems rather than strengthening them.

The Window That Remains Open

The gains of the twenty-first century are not lost. The WHO states this clearly in its report, and the data confirm it: levels of child mortality and HIV transmission reached in 2024 are incomparable to those in 2000. The question is not whether progress has occurred—it has—but whether it can be consolidated in a context of degraded financing.

Several levers exist. The first is the mobilization of domestic financing in the countries concerned. The WHO has for several years been pushing for middle-income countries to increase their share of public health spending to a minimum of 5% of GDP, a threshold recognized as necessary to ensure basic universal health coverage. Many are still far from it.

The second lever is coordination between private and public financiers. The Gates Foundation, GAVI, the Global Fund, and European donors are redesigning their priorities in this new context. This coordination is difficult, but it is not impossible: the mechanisms exist, the institutions are in place.

The third lever, less discussed, is technological. Low-cost diagnostic tools, single-dose vaccines, community monitoring platforms developed since the Covid-19 crisis have lowered the unit cost of many health interventions. It remains to be seen whether these productivity gains can partially compensate for losses in financing.

The fundamental political question remains posed: will wealthy democracies that committed to the Sustainable Development Goals in 2015 maintain these commitments in a context of internal budget pressures and rising nationalism? The WHO report does not answer this question. It poses it with data.

Sources

  1. WHO, World Health Statistics 2026 — https://www.who.int/news/item/13-05-2026-global-health-gains-face-threat-of-reversal
  2. UNAIDS, Global AIDS Update 2023 — https://www.unaids.org/en/resources/documents/2023/2023-unaids-global-aids-update
  3. Global Fund to Fight AIDS, Tuberculosis and Malaria — cumulative results since 2002, according to Global Fund annual reports
  4. Rwandan Ministry of Health — data on Mutuelle de Santé coverage, cited in WHO and World Bank reports
  5. Copenhagen Consensus Center, Best Buys in Global Health, 2023 — no link (report available on the organization’s website)
  6. UNAIDS Fact Sheet 2025 (HIV) — https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf
  7. WHO/UNICEF, Levels & Trends in Child Mortality, March 2026 — https://www.who.int/news/item/18-03-2026-progress-in-reducing-child-deaths-slows-as-4.9-million-children-die-before-age-five
  8. WHO/UNICEF/UNFPA, Trends in Maternal Mortality 2000-2023, April 2025 — https://www.who.int/news/item/07-04-2025-aid-cuts-threaten-fragile-progress-in-ending-maternal-deaths-un-agencies-warn
  9. Global Fund, Results Report 2025 — https://www.theglobalfund.org/en/results/
  10. HIV.gov / PEPFAR official data — https://www.hiv.gov/federal-response/pepfar-global-aids/pepfar
  11. UNICEF Data, Maternal Mortality — https://data.unicef.org/topic/maternal-health/maternal-mortality/