Advancing the Lusaka Agenda: the Global Financing Facility’s missed opportunities for catalysing sustainable health investment

This Commentary is part of the <i>Global Health Action</i> Special Issue titled <i>Global Financing Facility for Women, Children and Adolescents: Examining National Priorities, Processes and Investments</i>. The Issue examines the Global Financing Facility (GFF) through the lens of nine papers that explore the content and development processes of GFF country documents. While the GFF achieved technical alignment with national reproductive, maternal, newborn, child, and adolescent health priorities, it did not consistently translate into the mobilization of increased domestic resources. Loan-heavy financing structures substituted, rather than supplemented, public spending and intensified fiscal pressure in debt-constrained contexts. The expansion of results-based financing models has brought additional sustainability and equity concerns, with many initiatives collapsing post-project due to inadequate alignment with public finance systems. This falls short of the Lusaka Agenda's strategic shift towards country-led sustainable financing. Stakeholder engagement, particularly in civil society organizations, is often late, limited, or superficial. The neglect of stillbirth and respectful maternity care in the GFF documents calls for a critical look at high impact underprioritized areas when making future GFF investment decisions. As global health aid retracts and low- and middle-income countries navigate debt pressures, global health initiatives must base investments in disease burden data and engage stakeholders meaningfully. To realize the Lusaka Agenda's vision, the GFF must align with national public finance systems and secure sustainability beyond donor cycles.