2025 Year-in-Review:
Global Health at a Crossroads
Dr. José M. Zuniga, President/CEO, Fast-Track Health
If the past year in global health can be described in a single word, it is reckoning. Reckoning with political decisions that have reshaped and, in some cases, dismantled longstanding global health architectures. Reckoning with the limits of siloed disease responses in a world facing intersecting crises. And reckoning with the uncomfortable reality that time is no longer an abstract constraint, but an unforgiving variable as the 2030 deadline for the Sustainable Development Goals (SDGs) rapidly approaches.
At Fast-Track Health, my colleagues and I experienced 2025 as a clarifying moment for the future of the global health ecosystem. The turbulence of the year sharpened our purpose, reinforced our commitment to cities and communities, and compelled us to argue more forcefully for integrated, diagonal approaches to health in an era defined by polycrisis. 2025 was a year that demanded honesty about what is no longer working and courage to imagine what must come next.
A Fractured and Politicized Global Health Architecture
The global health ecosystem emerged from this year markedly altered. Political decisions – particularly in high-income countries that have historically underwritten global health responses – have decimated, reorganized, or deprioritized critical institutions, funding streams, and technical capacities. Longstanding norms around multilateralism, evidence-based policymaking, and shared accountability have been weakened, replaced too often by short-term political calculus and ideological retrenchment.
These shifts have had tangible and destabilizing consequences. Coordination gaps have widened across agencies and regions. Technical assistance pipelines have thinned or disappeared altogether. And the once-reliable scaffolding that supported progress across HIV, tuberculosis, viral hepatitis, maternal and child health, and immunization has become unpredictable and fragile. Even where funding nominally persists, uncertainty has become a defining feature that is complicating planning, undermining workforce stability, and eroding trust among implementing partners and communities alike.
Beyond institutional disruption, the erosion of trust has been one of the most damaging consequences of this year’s political realignment. Governments, civil society organizations, and implementing partners have been forced to recalibrate expectations about reliability, continuity, and good faith engagement. This has had a chilling effect on innovation and risk-taking, precisely when adaptive leadership is most needed. For many low- and middle-income countries, the signal has been unmistakable: self-reliance must accelerate even as fiscal space narrows, underscoring the urgency of new financing models, regional cooperation, and subnational leadership to fill the void left by retreating global actors.
Decimation and Reorganization of Multilaterals
The past year has witnessed an unprecedented decimation and reorganization of the multilateral health architecture that has underpinned global health progress for decades. UN agencies such as the WHO have faced not only chronic underfunding but sustained political attacks that have sought to weaken their authority, constrain their mandates, or fundamentally reshape their roles. Staffing reductions, budget freezes, and forced programmatic reprioritization have compromised institutional memory and technical capacity at a moment when global coordination is more essential than ever. These pressures are not merely cyclical; they reflect a deeper challenge to the legitimacy and independence of multilateral health governance itself.
Catalytic financing mechanisms have fared little better. The Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance – two of the most successful global health investments in modern history – continue to operate under conditions of heightened uncertainty. While recent replenishment efforts have demonstrated continued international support, funding levels remain fragile and increasingly vulnerable to political volatility in donor countries. Even when headline pledges appear strong, delayed disbursements, earmarking, and shifting priorities threaten the predictability that recipient countries will rely on to sustain life-saving programs. The result is a growing disconnect between global ambition and operational reality on the ground.
Compounding these challenges are continuing and emerging threats that place the entire multilateral ecosystem at risk. Proposals to sunset or radically narrow the mandate of UNAIDS, weaken WHO’s normative authority, or reframe global health as primarily a matter of national security rather than collective responsibility represent inflection points with long-term consequences. These dynamics risk unraveling decades of progress built on solidarity, shared accountability, and evidence-based action. In their absence, countries are increasingly left to navigate complex health threats alone. This stark reality underscores the urgency of defending, reforming, and modernizing multilateral institutions rather than allowing them to be hollowed out by neglect or politicization.
A Year of Too Many Missed Multilateral Moments
This year also placed a stark spotlight on the limits and vulnerabilities of global political processes. The Political Declaration on Noncommunicable Diseases and Mental Health was not adopted at the UN High-Level Meeting on NCDs in September 2025, following deliberate U.S. efforts to derail consensus, forcing the declaration to be referred to the UN General Assembly for a formal vote. While the declaration ultimately passed with 172 countries voting in favor, one abstention (Paraguay), and two votes against (Argentina and the United States), the episode exposed how political sabotage can undermine collective action even in the face of overwhelming global agreement around time-bound actions proportionate to the fact that NCDs account for nearly three-quarters of global death.
Similarly, the COP30 negotiated decision text (sans U.S. engagement) proved anemic. The most widely noted failure of COP30 was the omission of any reference to fossil fuels in the official text, even though more than 80 countries had pushed for a roadmap towards phasing down coal, oil, and gas. And, despite overwhelming evidence that cities are on the front lines of climate impacts and thus uniquely positioned to drive mitigation and adaptation, the framework failed to prioritize urban action or explicitly integrate health as a central climate outcome. Once again, climate and health were treated as adjacent rather than inseparable. Compounding these shortcomings, the decision text lacked binding commitments, credible timelines, and dedicated financing mechanisms to translate ambition into accountable action.
Other global processes fared no better: momentum towards a robust pandemic accord was uneven and protracted, universal health coverage commitments remained under-resourced, and UN reform debates emphasized efficiency over mission. Here, too, the United States played a defining foil, with its decision to withdraw from the WHO marking a critical turning point in modern global health governance and weakening confidence in multilateral cooperation at precisely the moment it was most needed.
Collectively, these failures underscored a troubling pattern of global consensus without consequence. These shortcomings matter because of what they signal about the current multilateral moment. Declarations and frameworks increasingly function as political placeholders rather than engines of change. Without enforcement, financing, and local accountability, they risk eroding trust in multilateralism itself and accelerating fragmentation across the global health ecosystem.
Disease Burden Without Silos
While political declarations and public health responses faltered, disease burdens did not wait. Communicable diseases continue to exact a heavy toll. HIV remains a stark example: scientific advances have made epidemic control achievable, yet political backsliding and funding disruptions threaten to reverse hard-won gains, especially among marginalized populations. The significantly hobbled U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), one of the world’s most successful public health programs, is a revealing case study in this regard.
At the same time, NCDs – cardiovascular disease, diabetes, cancers, chronic respiratory illnesses – have surged, increasingly co-existing with infectious diseases within the same individuals and communities. Mental health conditions have intensified in the wake of conflict, displacement, economic precarity, and climate-related disasters – in many cases exacerbating the mental health burden from the COVID-19 pandemic. These realities expose the inadequacy of vertical responses that treat conditions in isolation, divorced from the social, economic, and environmental contexts in which people live and seek care.
Climate change has further collapsed any illusion that health challenges can be neatly categorized. Extreme heat, air pollution, flooding, drought, and food insecurity are already reshaping disease patterns, overwhelming health services, and worsening inequities that fuel morbidity and mortality. Health systems are no longer preparing for future climate impacts; they are responding to them in real time, often without the tools, financing, or policy support required. Meanwhile, the response to the health impacts of climate change are needlessly in siloes at a time when a high tide could help lift all boats.
Importantly, the convergence of disease burdens has exposed how poorly most health systems are structured to manage multimorbidity across the life course. Patients are still forced to navigate parallel clinics, fragmented records, and inconsistent standards of care. This fragmentation disproportionately affects those already marginalized, particularly people living in informal urban settlements or climate-vulnerable regions. Addressing disease burden without silos therefore requires technical integration, policy reform that prioritizes continuity of care, primary health systems, and person-centered models grounded in lived reality.
Cities as the Crucible of Solutions
In this unsettled global landscape, cities have emerged not merely as sites of vulnerability, but as engines of possibility. Urban areas concentrate risk – but they also concentrate leadership, innovation, service delivery capacity, and lived experience. Cities are where health systems intersect most visibly with housing, transport, education, labor markets, and climate adaptation strategies. As national and multilateral responses falter, cities are increasingly where pragmatic, equity-driven solutions are being tested, implemented, and sustained.
Fast-Track Health’s deep engagement with the Fast-Track Cities network reflects this conviction. With more than 600 cities worldwide committed to advancing health equity and accountability, the network has evolved far beyond its origins in HIV. Today, it represents the largest coordinated urban health initiative globally – one uniquely positioned to operationalize integrated responses across communicable diseases, NCDs, and climate-related health threats, even when national or global leadership falters. Through this platform, Fast-Track Health helps translate global commitments into locally accountable action, grounded in data, community partnership, and implementation science.
This vision will be on full display at the global Fast-Track Cities 2026 conference in Berlin, where Mayors, health leaders, community advocates, researchers, and private-sector partners will convene to chart a path towards the 2030 deadline and beyond. The conference is a declaration that cities matter, that subnational leadership is indispensable, and that practical, data-driven action can still outpace political inertia. At a moment when global frameworks are faltering, the conference will serve as a proving ground for what integrated, city-led health action can achieve at scale.
Cities are also where political pragmatism often outpaces ideology. Municipal leaders are increasingly willing to experiment – deploying data dashboards, integrating health into climate adaptation plans, and forging cross-sector partnerships that deliver tangible results. Urban governance allows for proximity to communities, faster feedback loops, and more agile responses to emerging threats. Fast-Track Health views cities not as subordinate implementers of national policy, but as laboratories of the post-SDG era capable of demonstrating what integrated, accountable, and people-centered health systems can look like at scale.
Community Engagement: From Exception to Expectation
One of the clearest lessons of the past four decades of the HIV response is that durable progress is impossible without communities at the center. Community leadership transformed HIV from a fatal diagnosis into a manageable condition, reshaped clinical research, accelerated access to treatment, and embedded human rights into health practice. That same model of empowered, resourced, and accountable community engagement must now be applied across all health and climate challenges if progress is to be sustained.
Yet this level of community engagement remains the exception rather than the norm across global health. As Fast-Track Health looks across NCDs, climate-health responses, and emerging threats, the imperative is clear: community engagement on all levels, including faith communities, must be elevated to the same level of influence, resourcing, and respect that the HIV movement achieved. Communities should not be viewed as merely beneficiaries of interventions; they must be co-designers, implementers, and accountability partners. In an era of misinformation, distrust, and widening inequities, their role is not optional; it is foundational.
Crucially, authentic community engagement also functions as a corrective to enduring power imbalances in global health. When communities are excluded, interventions risk irrelevance or harm; when they are meaningfully included, outcomes improve and legitimacy follows. The HIV movement demonstrated that communities can challenge systems while simultaneously strengthening them. Fast-Track Health believes this model must now be normalized across disease areas and climate-health responses – moving beyond consultation towards shared governance, sustained financing, and institutionalized roles for lived experience in decision-making.
Breaking Silos Through Diagonal Thinking
If 2025 revealed anything with painful clarity, it is that silos are a luxury the world can no longer afford. Disease-specific funding streams, fragmented data systems, and compartmentalized expertise may offer administrative simplicity, but they fail people whose health realities are complex and interconnected. Breaking these silos is not merely a technical challenge, but a political and institutional one that demands new incentives, partnerships, and measures of success.
Fast-Track Health therefore advances diagonal approaches that leverage disease-specific investments to strengthen health systems, address shared risk factors, and deliver integrated care that take into account multiple dimensions of health, including emotional and spiritual. These approaches demand collaboration across sectors and, at times, across unlikely partnerships: public health agencies collaborating with urban planners; climate scientists collaborating with primary care providers; private industry engaging with municipal leaders; and faith communities supporting stigmatized communities. These “strange bedfellow” partnerships are not signs of compromise; they are signs of realism.
Diagonal approaches also offer a pathway to greater efficiency and resilience at a time of constrained resources. By aligning investments across diseases, sectors, and determinants, health gains can be amplified rather than diluted. This requires funders to tolerate complexity, policymakers to relinquish rigid mandates, and institutions to measure success differently – valuing system-level outcomes alongside disease-specific indicators. While more demanding, diagonal strategies better reflect the realities of human health in a changing world and offer one of the few credible routes to progress within the shrinking timeline to 2030.
Top Opportunities for Global Health Action
The following five opportunities represent concrete, actionable ways to move from critique to construction, and from ambition to delivery.
- Center Cities as Engines of Health Action. Cities have demonstrated the capacity to act decisively where national and multilateral systems are constrained or stalled. Elevating city-led leadership through networks like Fast-Track Cities offers a practical pathway to translate global goals into accountable, locally delivered health outcomes.
- Adopt Diagonal, Integrated Health Approaches. Breaking down silos between communicable diseases, NCDs, mental health, and climate-related health impacts can unlock efficiencies and improve outcomes across the life-course. Diagonal strategies that strengthen primary health systems while addressing shared risk factors are essential in an era of constrained resources and overlapping crises.
- Elevate Community Engagement to a Systemic Norm. The HIV response proved that empowered, resourced communities are not ancillary but central to sustainable health progress. Applying this model across all disease areas and climate-health responses can restore trust, improve implementation, and strengthen accountability from the ground up.
- Reform and Defend Multilateral Health Institutions. Rather than allowing multilateral agencies and catalytic financing mechanisms to be hollowed out, there is an opportunity to modernize them for a more volatile, urbanized, and climate-constrained world. Protecting their normative authority while aligning them more closely with subnational and urban action can restore relevance and impact.
- Use the 2030 Deadline as a Catalyst, Not an Excuse. With many global targets off track, the remaining years to 2030 must be treated as a period of accelerated delivery rather than deferred ambition. Simultaneously designing post-SDG governance and financing models, while holding current commitments accountable, can prevent another cycle of aspiration without execution.
Time Is Not Our Friend and Neither Is Complacency
As the world races towards 2030, the distance between ambition and action has become increasingly stark. Many global targets across HIV, NCDs, climate adaptation, and universal health coverage are off track. At the same time, conversations have already begun about what comes after the SDGs, even as current commitments remain unmet. This tension risks normalizing delay unless urgency, accountability, and delivery are re-centered as non-negotiable priorities.
Fast-Track Health believes these conversations must happen in parallel. We cannot defer accountability for existing promises while envisioning a post-SDG era. The urgency of now demands acceleration, course correction, and the construction of governance and financing models fit for a more volatile, urbanized, and climate-constrained world. This dual focus –delivering today while designing tomorrow – must define the next phase of global health leadership. Anything less risks repeating the cycle of ambition without execution that has left too many goals unmet and too many communities behind.
The temptation to defer tough decisions to a post-2030 framework is understandable but dangerous. Every year of delay compounds inequities and forecloses options, particularly in climate-vulnerable and rapidly urbanizing regions. Fast-Track Health argues that urgency must coexist with imagination: accelerating action on current targets while deliberately designing the governance, financing, and accountability structures of the next era. The post-SDG world should not emerge by default or fatigue, but by design and rooted in integration, local leadership, and the hard lessons of this pivotal decade.
Taken together, the challenges of the past year make one thing clear: incrementalism is no longer sufficient, and neither is nostalgia for systems that no longer function as designed. Yet within disruption lies opportunity if global health actors are willing to rethink where leadership resides, how accountability is enforced, and whose voices shape solutions. As we journey forward amid accelerating climate, political, and epidemiological pressures, the path forward demands focus, integration, and courage.