(PEPFAR COP25 Strategic Guidance), and similarly, the United States Agency for International Development (USAID) tightened cost-sharing rules for recipient governments.52 Estimates for 2025 indicate further worsening, with global DAH declining by an additional $11 billion,53 largely because US funding agencies are expected to cut about $9 billion.54 As a result, it is not surprising that many council members and executives expect cooperation in this pillar to deteriorate further (Figure 10). Health outcomes have not yet started to reflect the potential impacts of the shift taking place. In 2024, all health outcomes – including disability-adjusted life years (DALYs), life expectancy, child mortality and maternal mortality – showed progress. However, health outcomes often lag their drivers significantly, and these improvements might be capturing a post- pandemic rebound, and perhaps also the results of longer-term cooperation. Although these indicators reflect positive outcomes, other evidence points to a widening gap between “healthspan” and lifespan,55 as health-adjusted life expectancy lags gains in life expectancy. Put simply, this means people are living more years with illness. Despite a slowdown in overall goods trade (as discussed in the trade and capital pillar), trade in health goods increased in 2024. This increase was propelled by innovation-led demand in pharmaceuticals – most visibly a rise in GLP-1 therapies, and exports from hubs such as Ireland, Denmark and Switzerland feeding US/EU demand. The WTO’s “zero-for-zero” deal also kept pharmaceuticals tariffs near zero.56 Recent global multilateral efforts – such as WHO’s Pandemic Agreement (though not yet ratified and without US participation57) and the UN General Assembly’s declaration on non-communicable diseases and mental health – signal continued commitment to coordination in global health governance. Meanwhile, regional cooperation is gaining definition, exemplified by the Organisation of Eastern Caribbean States scaling a model to reduce the price of insulin throughout the region, the launch of the African Medicine Agency, as well as the Accra consensus, with African governments aligning on shared priorities and execution.58 Looking ahead, the critical question is the extent to which fading global multilateral efforts could translate into worse health outcomes. As global financial flows weaken and the remaining support flows limit their coverage to treatment and delivery, pressures on domestic health budgets will rise. Many domestic economies will be unable to make up for the shortfall, and the test ahead will be whether progress on health outcomes can be sustained. As global financial flows weaken and the remaining support flows limit their coverage to treatment and delivery, pressures on domestic health budgets will rise. The Global Cooperation Barometer 2026 22