At least one more governmental seat for Africa: stronger voice, better health

At least one more governmental seat for Africa: stronger voice, better health

16 September 2025 - Wits University

It is time to increase Africa's governmental representation on the governing board of the global fund to fight AIDS, TB and malaria.

Health funders would likely have a better return on investment and a stronger position in the global funding crisis if Africans had greater decision-making influence and voting power in global health institutions.

This is an assertion in an article published on 15 September 2025 in the prestigious BMJ Global Health journal.

Africa carries the burden, but not the votes or the power

Currently, Africa receives 71% of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GTAFM) funds, yet holds only 10% of voting seats on the institution's governing board.

One additional government voting seat would not only align with global norms and declarations but also strengthen African health policy, accountability, aid effectiveness, and sustainability, through increased participation in decision-making that is of direct concern to their health systems.

"Funding decisions largely affect Africans, and yet their voices are systematically minimised. Beyond having greater representation on the GTAFM Board, we are advocating for a complete shift in the global health institutional architecture," says Robyn Hayes-Badenhorst, Founder and Co-Executive Director of Supporting Health Initiatives (SHI) at Wits University, and co-author of the article.

This rebalanced global health environment is of critical importance, notably as the GFATM confirmed in July that it is cutting US$1.43 billion in funding already allocated for its current funding cycle. This followed uncertainty and upheaval as the US froze funding and then dismantled the US Agency for International Development (USAID). More recently, Germany announced plans to reduce its funding for global health aid further. Indeed, GFATM will receive US$117 million less over the coming years.

A crisis moment opens the door for reform

"While these funding cuts happened far too quickly and harshly, it is an opportunity for radical reform in the global health institutional system. If we start doing this by adding at least one governmental voting seat on the GFATM board, we can begin to push for better strategic investments for the promotion of self-reliance, which would meaningfully enhance long-term health and well-being for the most vulnerable," says Professor Garrett Wallace Brown from the University of Leeds, who led the SHI research.

Sustainable domestic financing is the way out from external financial dependency. However, domestic financing is inextricably linked to the global health architecture and governance. Only purposeful reforms toward balanced decision-making will bring about the change that is not only needed but overdue, says Magda Robalo, who supports the Africa Health Sovereignty agenda initiated by the President of Ghana and was until recently at the helm of the Ethics and Governance Committee of the Global Fund.

Will at least one more seat make a difference?

Hayes-Badenhorst acknowledges that at least one additional seat may not seem a substantial change, but it is part of the urgent movement to build Africa's self-reliance in healthcare. "This is long overdue. Since 2005, there has been a call for more inclusive governance. When Africa has health security, so does the rest of the world."

The Paris Declaration on Aid Effectiveness, the Lusaka Agenda, past G20 commitments, and the Accra Declaration on Universal Health Coverage are signals of the need for meaningful African representation, decision-making, and ownership.

Africa's two voting seats (one for Eastern and Southern Africa, and the other for Western and Central Africa) cover 47 countries with vastly different health challenges. At least one additional seat will reduce the existing seats being overwhelmed and allow for more focused, responsive and meaningful participation, beyond tokenism. "Incremental change matters in governance bodies," says Dr Lieve Fransen, who was GFATM's founding chair and Board vice-chair.

The BMJ Global Health article complements a larger report coordinated by SHI at Wits University, titled Increasing African Government Membership on the Global Fund to Fight AIDS, Tuberculosis and Malaria. This report provides compelling empirical evidence that better representation enhances ownership, contextualisation, and sustainability. "These are all critical for aid effectiveness," said Fransen.

Domestic commitments must be met

Part of the radical reform needed in global health is Africa's commitment to increase domestic obligations to meet its Abuja Declaration target of allocating 15% of the national budget to health. Currently, only three African countries consistently meet their targets. Increased domestic financing unlocks co-financing incentives with large donors. However, Africa needs to be supported in bolstering its technical, administrative, and leadership capacities, which are currently hindered by power imbalances. Only 57% of GFATM financing flows through public systems, which hinders capacity building and the strengthening of health systems.

"Donors will expect accountability and efficiency, and Africa-first initiatives will do this. Greater African board representation has, however, been shut down. We know that board reforms will future proof the GFATM," says Brown.

A timely moment for reform

The BMJGH article and corresponding Report are timely and strategic. They have been released just before the G20 meeting in South Africa, where global leaders will be discussing commitments to inclusive governance and resilient health systems.

"We need a strong voice at the G20 and other high-profile gatherings to advocate for an extra governmental seat. This would further lay the ground for equitable, resilient, and sustainable health systems to improve health globally. Moreover, enhanced representation will empower African governments to share health policies that reflect local realities, improve programme sustainability and reduce reliance on external actors," says Hayes-Badenhorst.