In January 2025, the world's largest health donor walked out. The US withdrawal from the WHO and the dismantling of USAID undid in four months what decades had built: over 2,000 WHO redundancies, many USAID-funded staff displaced, PEPFAR's HIV treatment pipeline severed across Sub-Saharan Africa, and Gavi capping malaria vaccination coverage at 70%, previously its minimum target for countries. The global health system has been calculating the cost ever since.
 

Drawing on 27 semi-structured expert interviews conducted across Switzerland, the US, and Sub-Saharan Africa, this research triangulates institutional and country-level perspectives through a decolonial lens to ask how the withdrawal has reshaped global health governance—financially, structurally, and politically—and whether the adaptations underway constitute the decolonising shift the field has rhetorically promised for decades.
 

The findings cut against the rhetoric of rupture. Donor concentration, disease silos, and partnership discourse that obscures structural asymmetries had been the system's operating logic long before January 2025; the shock has ended the consensus that allowed them to persist. The substitutes hold less than advertised: innovative finance cannot match ODA's volume, and philanthropy faces financial, strategic, and legitimacy limits that prevent wholesale substitution. Most critically, bilateral instruments such as the Kenya–US Cooperation Framework trade away fiscal autonomy in exchange for the knowledge systems that autonomy requires. Nevertheless, African leadership is consolidating where the architecture's crisis has opened space: initiatives such as Africa CDC, the Accra Reset, and the Lusaka Agenda show that the decolonising agenda is no longer purely rhetorical.