The past decade has been a “golden window” for global health.1 New disease specific health initiatives and major new funding programmes have contributed to impressive gains.2 3 In 2008, for example, 10 000 fewer children were dying each day than in 1990.3 But there are disturbing signs that the window may be closing.

Donor agencies have warned African countries that financial help for HIV treatment programmes cannot be assured.1 The Global Fund to Fight AIDS, tuberculosis, and malaria and the Global Alliance for Vaccines and Immunisation (GAVI Alliance) face serious funding shortfalls. The Spanish government just announced that it will cut foreign aid by €600m (£506m; $734m) as part of its austerity measures, and other donor governments seem likely to follow suit.4 Without sustained funding to strengthen the fragile health infrastructure of developing countries, the millennium development goals are unlikely to be reached.

How will the global health community respond? One risk is that the various sub-communities, or silos, such as those working on HIV, malaria, vaccines, or health systems, will advocate and compete for their own stake in the shrinking pot of donor money.

A more rational response would be for the community to come together and agree on a “cross cutting” agenda for global health. Such an agenda should focus on how to get the overall global health architecture right, and how to ensure maximum return for every dollar invested.

This agenda should tackle four key areas. A better …