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Abstract Background The Covid pandemic and its aftermath have triggered new alarm and social unrest across the Global South over the deepening international debt crisis that now threatens to derail Universal Health Coverage (UHC), other Sustainable Development Goals (SDGs), future pandemic preparedness, and global warming mitigation. The recent Globalization and Health article by Alex Kentikelenis and Thomas Stubbs (May 2024), “Social protection and the International Monetary Fund: promise versus performance”, offers a meticulously quantified rendering of the social costs imposed by the crisis and takes aim at IMF solutions. They advocate for a rejection of IMF austerity programs and offer a valuable prescription for change through the International Labor Organization’s “Universal Social Protection” concept. Main body Similar to the Jubilee movement at the turn of the century, global civil society, humanitarian aid, and health organizations are mobilizing in a variety of global networks to call for debt cancellation and restructuring as well as an end to austerity. These include new debt law campaigns in London and New York to rein in private creditors, calls for new IMF issuance of “Special Drawing Rights”, demands for “Global Public Investment”, and promotion of Universal Social Protection. Conclusion The Universal Social Protection approach described by Kentikelenis and Stubbs provides a focal point for these demands to confront this latest and worst episode of sovereign debt crisis already undermining global health progress.

Abstract In many African countries, hundreds of health-related NGOs are fed by a chaotic tangle of donor funding streams. The case of Mozambique illustrates how this NGO model impedes Universal Health Coverage. In the 1990s, NGOs multiplied across post-war Mozambique: the country’s structural adjustment program constrained public and foreign aid expenditures on the public health system, while donors favored private contractors and NGOs. In the 2000s, funding for HIV/AIDS and other vertical aid from many donors increased dramatically. In 2004, the United States introduced PEPFAR in Mozambique at nearly 500 million USD per year, roughly equivalent to the entire budget of the Ministry of Health. To be sure, PEPFAR funding has helped thousands access antiretroviral treatment, but over 90% of resources flow “off-budget” to NGO “implementing partners,” with little left for the public health system. After a decade of this major donor funding to NGOs, public sector health system coverage had barely changed. In 2014, the workforce/ population ratio was still among the five worst in the world at 71/10000; the health facility/per capita ratio worsened since 2009 to only 1 per 16,795. Achieving UHC will require rejection of austerity constraints on public sector health systems, and rechanneling of aid to public systems building rather than to NGOs.