In 2005, the Paris Declaration on Aid Effectiveness promised a new deal between donors and countries—anchored in ownership, alignment, harmonisation, results, and mutual accountability. Much of the first decade of Agulhas’s work focussed on evaluating the implementation of the Paris agenda. Its principles underpinned many of the concepts the UK’s Independent Commission for Aid Impact has applied in assessing the effectiveness and value for money of UK ODA spending. Paris shaped the language of global partnership for a generation.
But while Paris helped improve technical coordination to deliver ODA, it did not fundamentally shift power.
And now, as donor budgets have rapidly tightened (or disappeared), countries have been exposed. Many have simply not committed enough to health spending, particularly lower middle-income countries chasing rapid economic growth.
The shocks of U.S. government cuts are still being felt—most acutely for people with HIV, TB, and malaria. The global health community is witnessing the harsh consequences of its dependent architecture. Antiretroviral supply chains are disrupted. Paediatric AIDS services are being paused. TB programs are scaling down. Malaria elimination timelines are slipping further out of reach.
Amid this crisis, the 2023 Lusaka Agenda has been seen by some as a roadmap for renewal. If Paris was about making aid better, Lusaka is about making aid less necessary. It calls for a radical rebalancing of roles: donors must become supporters, not directors; implementers must follow government priorities, not donor checklists.
Where Paris urged better coordination, Lusaka demands country leadership in practice—not just in policy. And, of course, spending.
This point was driven home to me this week in meetings I’ve been attending in Geneva around the World Health Assembly. I’ve heard many voices agreeing: the current model has been proven to be no longer sustainable. And the stories we’ve all been telling ourselves about how to use ODA to build sustainable systems have been exposed as wishful thinking at best, fictional at worst.
So the current moment—though painful—is also a chance to break from the past. The recent actions of donors is the opportunity of a generation to radically change mindsets, partnerships and power. The Lusaka principles must shift from theory to practice. That means letting countries lead—not just as beneficiaries, but as the architects of their own health futures.
And that requires rethinking how global institutions align behind the new reality.
Country ownership of aid has long been part of donor rhetoric. We’ve known this for many years. In a series of projects Agulhas did for the Open Societies Initiative and the Gates Foundation on reimagining technical assistance, we concluded that ultimately, this required redefining power relationships to enable true partnership.
Here in Geneva, leaders from some traditionally recipient countries are articulating something beyond just a shift in power; a renewed aspiration. They do not want the lives of their citizens to be at the whim of donors. Even in the absence of domestic resources, countries can—and must—set ambitious, strategic priorities. And there should be a real shift of mode, with funders truly aligning behind those agendas, not the other way around.
The wholesale cuts from donor countries prove that aid is never, was never, truly guaranteed. What matters now is whether global health actors use this moment to do what Paris couldn’t: truly dismantle dependency.
