Rethinking the roles of aid, markets, and incentives in building resilient health systems.
“The biggest barrier to private-sector scaling in any way that provides public benefit is that the market has been cornered by NGOs, and donors are paying for that.” —Zipline Africa CEO Caitlin Burton at the 2026 World Health Assembly
Across global health, there is growing openness about what is and is not working, especially around aid dependency, market distortion, and the limits of current delivery models. Some argue that aid systems have unintentionally constrained local market development. Others point out that withdrawing support too quickly, before resilient national systems exist, can create real risks in areas such as outbreak response.
Both perspectives contain truth but suffer from historical amnesia. Markets like these did not just appear; they were built and matured.
For decades, there was no “market” to be cornered. What often gets lost is that this is not really about which sector is “right.” It is a question of how health systems and markets are built in the first place.
In many low-income settings, there was often no viable market to crowd out. There were patients who could not pay, governments without fiscal space, infrastructure gaps too costly to close, and risks no investor was willing to underwrite. Into that vacuum stepped publicly funded programs—often inefficient, yes; sometimes imperfect; but undeniably foundational.
They built supply chains where none existed, generated demand where none was visible, trained health workers, strengthened procurement systems, supported regulatory and contracting environments, and established the very conditions that make private participation conceivable today.
If these systems were truly so distortive, why did private capital not arrive sooner?
This question matters because it challenges an assumption embedded in much of this debate: that markets naturally exist and are later distorted by aid. But markets in such sectors are not waiting to emerge; they had to be built.
What we may be witnessing now is not the crowding out of markets but their late arrival, once the cost of entry has been substantially subsidized. Public and philanthropic systems absorbed the risks commercial entities would not: political risk, infrastructure risk, workforce risk, last-mile delivery risk, and the realities of serving populations with limited purchasing power.
This does not mean critiques of the aid sector are invalid. Donor-funded systems have, at times, created fragmentation, parallel reporting structures, dependency, and inefficient incentives. Some programs became more accountable to funding cycles than to long-term sustainability. These are not trivial failures, and they deserve scrutiny. Nor is this to dismiss the role of the private sector. Its contribution to innovation and execution is real, often impressive.
But framing the challenge as “NGOs versus the private sector” risks creating a false binary that obscures the more important question: What capabilities does a system actually need, and what arrangements best sustain those capabilities over time? Too often, global health debates confuse actors with functions. The question is rarely whether governments, NGOs, donors, or private firms should dominate. The real question is whether the overall system aligns incentives, financing, accountability, and operational capacity toward sustainable public health outcomes.
Governments provide stewardship and legitimacy. Donors provide catalytic financing. Nonprofits bring flexibility and technical capacity. The private sector contributes innovation and operational efficiency. Communities provide trust and accountability.
The challenge is not the presence of any one actor. It is whether incentives, financing, and accountability are aligned in ways that allow these functions to reinforce, rather than undermine, one another over time.
In practice, grant funding has often functioned as de facto early-stage capital. It has financed infrastructure, de-risked delivery models, and helped generate demand where none previously existed. To characterize those same systems as “market distortion” once commercial viability emerges risks misunderstanding the sequence by which markets are actually formed.
What is often missing from these conversations is a more honest discussion of incentives. Much of the global health sector still speaks primarily in moral language while avoiding the political and economic realities that shape institutional behavior. Donors operate under political cycles and pressure for measurable results. NGOs must sustain operations and workforce. Governments seek sovereignty and legitimacy. Companies require predictable revenue and return on investment. Communities seek trustworthy and accessible services. None of these incentives are inherently wrong. Problems emerge when they remain hidden or poorly aligned with long-term public health goals.
A more useful exercise is to examine what capabilities a system actually needs and what arrangements best sustain those capabilities. Global health does not need less ambition. It needs more honesty about incentives, trade-offs, and what sustainable transition really requires. Resilient systems are not built through permanent external substitution, but neither are they built through abrupt withdrawal before sufficient capability exists.
Sustainability is not an event; it is a managed transition.
We believe the future of global health will not be secured by defending existing institutions or replacing them wholesale, but by understanding, codifying, replicating, and enhancing the sequence through which sustainable systems emerge.
The future should not be built by deciding which sector should win. If the question becomes which model should triumph, everyone loses.
Tigistu Ashengo (Tigi) MD, MPH is Jhpiego's Chief Medical Officer. Anunaya Jain is the Technical Director for the Digital and Data Analytics Hub at Jhpiego.
