Ask most global health professionals what the binding constraint is today, and they will tell you the same thing: money. Not frameworks. Not technical guidance. Abrupt reductions by major donors such as France, Germany, and Japan, as well as the UK and US, have created systemic shock. These partners had historically co-financed the backbone of health systems and health security: surveillance systems, laboratory networks, workforce development, and operational readiness. Their withdrawal has already disrupted national health security plans, jeopardizing years of hard-wrought progress. Sierra Leone illustrates the problem acutely. More than half of the activities in its first National Action Plan for Health Security (NAPHS) went unfunded. 2 Its second NAPHS launched with only 21% of its 91. 6 million budget secured. 3 Sierra Leone is not an outlier. At least 25 low-and middle-income countries rely on external financing for more than 30% of their health budgets, leaving them little scope to absorb donor withdrawal. Requisite fiscal space simply does not exist. The eight analyses make a consistent case for better aligning health security with universal health coverage (UHC). The two agendas are too often treated as rivals competing for scarce budgets, when they are deeply intertwined. A functioning primary care system is the first line of outbreak detection; investments in preparedness make routine service delivery more resilient. 4 The problem is that this logic, which is widely accepted in principle, has yet to be translated into practice. A consistent theme across this series is that health security remains poorly embedded in national planning and budgeting processes, particularly at lower levels, where the capacity to detect and respond to outbreaks matters most. This is even more profound for the environmental health sectors which are often grossly underfunded in most developing countries. Closing this implementation gap should be a priority. The NAPHS process has come a long way. Countries like Sierra Leone have made genuine strides in prioritization and operationalization that should be acknowledged. But a stubborn gap persists between finishing a plan and seeing measurable improvements in the core capacities assessed through the Joint External Evaluation (JEE). Fragmented M&E systems, donor-driven conditionality, and siloed implementation remain the main culprits. Getting NAPHS activities genuinely embedded within ministries, rather than managed by parallel project teams, strengthening One Health coordination across animal, environmental and human health and aligning monitoring and evaluation indicators would make a meaningful difference. Sierra Leone's decision to cost equity and human rights as explicit technical areas in its second NAPHS is the kind of innovation that deserves to be picked up more widely. 5 Tools, Data, and the Challenge of Prevention Risk assessment tools like WHO's Strategic Tool for Assessing Risks (STAR), useful as they are for setting priorities, often struggle when environments shift quickly. There is also a genuine paradox here: a tool that appears to have missed an outbreak may be recording the success of an intervention that stopped it from happening. This points to a broader methodological gap: evaluation frameworks that can incorporate counterfactuals, draw on real-time data, capture geographic variation and are more specific to country contexts are still largely missing from current practice. These tools also need to be redefined to better cover aspects of other sectors outside human health that contribute to health security. Two operational domains-knowledge management systems (KMS) and IPC-remain stubbornly underdeveloped. 6, 7 COVID-19 demonstrated the value of pre-established KMS for rapid decision-making, yet many countries still fall back on improvised, reactive approaches when crises hit. IPC infrastructure has improved on paper, but the operational components such as dedicated budgets, reliable supply chains, and trained and retained personnel continue to lag. These are not primarily technical failures but are the predictable result of underinvestment and fluctuating political priority. Taken together, the evidence points to four priorities that cut across all the analyses: • Domestic financing needs to be increased and made more predictable, built into systems rather than triggered only by emergencies. • Equity must be built into system design from the start, not retrofitted as a reporting category. • One Health needs workable operational models at the intermediate and community level, not just high-level political endorsements at international and national level. • We need better theories of change and longer-term evidence that connect investments to actual outcomes-without that, investment decisions and resource allocation will remain guesswork. The picture that emerges from these analyses is sobering but not hopeless. Health security systems have genuinely strengthened over the past decade. The problem is that their foundations remain fragile-and the current wave of donor contraction is putting real pressure on them. If health security is to function as a global public good, it requires sustained investment, credible political commitment, and partnerships built on national sovereignty rather than charity. That is not an aspiration: it is a political imperative. The time for concerted action is now.
Njeru et al. (Thu,) studied this question.