In the wake of unprecedented cuts in foreign assistance, supporting local civil society to advocate for greater country ownership and investment in public health is more critical than ever.
*This op-ed was originally published by Devex
With U.S. foreign assistance in disarray and the U.K. and Dutch governments pulling back on their global development commitments, decades of progress in combating life-threatening diseases and strengthening health systems is now at risk. Countries that have relied on aid will face growing pressure to finance their own health systems — accelerating a shift toward local ownership that has been underway for years. The question is: Who will lead this transition and ensure it succeeds?
Local ownership is the future of public health
International donors have long played a crucial role in supporting global public health. Between 2000 and 2019, external aid accounted for roughly 30% of low-income countries’ health budgets, with the remainder coming from domestic budgets and out-of-pocket spending. This funding not only supports countries’ health systems but also contributes to international stability and stops health threats before they cross borders.
Donor government cuts are harming millions of real people, causing preventable deaths and suffering. Reports are flooding in of mothers and babies losing access to lifesaving medications, malnourished children being denied the therapeutic food they need to survive, and efforts to prevent deadly diseases such as malaria and cholera from spreading being abandoned.
However, public health progress is only sustainable when ownership lies with the people and governments closest to the issues. Health policies define a country's public health system and shape the environments where people live and work. For these policies to be effective, they must reflect the needs and demands of the communities they serve. Governments must know their citizens are calling for action — and be held accountable when they fail to deliver.
Predictable, reliable, and sustainable health funding is essential. The 2001 Abuja Declaration, in which African Union heads of state committed to allocating 15% of their annual budgets to health, remains largely unmet. The same is true for donor countries’ pledges to fulfill their international development assistance commitments. As traditional donors retreat, the path forward lies in empowering countries to set, fund, and implement their own priorities.
Civil society: The catalyst for country ownership
Government action doesn’t happen in a vacuum. In every country, from the United States to Nigeria, civil society plays a pivotal role in shaping policy, generating political will, and holding leaders accountable.
Public health policies are created, changed, or sustained because some group demands it. The role of public health advocates is to ensure that the public’s interest is front and center — and that those most affected by policy outcomes have a voice in the process.
Nigeria provides a compelling example. Following sustained civil society advocacy, domestic funding for the Nigeria Centre for Disease Control, or NCDC, more than doubled between 2019 and 2021, reaching a record 2.9 billion naira ($7.7 million). Kano, one of the most populous states in Nigeria, adopted a new Action Plan for Health Security and allocated a dedicated budget line for epidemic preparedness and response. These victories demonstrate that civil society advocacy can drive tangible, lasting change.
Investing in advocacy: A smart, necessary strategy
However, civil society cannot do this work alone. Advocacy requires sustained, targeted investment — financial support, technical expertise, training, and tailored advocacy tools that fit specific political systems and cultural contexts.
Public health advocacy is inherently interdisciplinary. Successful campaigns draw on legal expertise, data generation, communications, decision-maker engagement, and rigorous monitoring and evaluation. Legal and litigation strategies, in particular, are essential. They ensure that policies are well-drafted, effectively implemented, and vigorously enforced. Strategic litigation is also critical for holding health-harming industries accountable and ensuring they pay for the harm they cause.
Our experience working across diverse political contexts in low- and middle-income countries demonstrates that when civil society organizations have the resources and technical support to advocate effectively, they can drive significant policy victories and lasting public health impact. We have seen this firsthand in more than 40 countries, where public health policies benefiting over 3.5 billion people have been successfully enacted
The lesson for us is this: If we want to protect global public health, we must support local civil society to lead the way.
As traditional donor governments turn inward, countries will need to step into the leadership vacuum. This shift will happen only if remaining donors — especially philanthropies — invest in advocacy at the country level. By expanding civil society’s capacity, donors can help governments pass, fund, implement, and sustain public health programs — and hold them accountable for doing so.
Global health progress is under threat. But there is a path forward. By doubling down on civil society advocacy, we can make health systems more resilient, responsive, and sustainable. The future of public health depends on it.