European Union: Multiannual financial framework

The EU’s 2028-2034 multiannual financial framework: Safeguarding humanitarian aid, global health and rights

Analysis and recommendations by Médecins du Monde International Network

In July 2025, the European Commission presented its proposal for the next Multiannual Financial Framework (MFF) for the period 2028–2034. Framed as a budget for a “new era”, the MFF is centred on flexibility, simplification and closer alignment with European Union (EU) strategic interests. At its core is the Global Europe Instrument (GEI), with a proposed envelope of €200 billion, to finance international cooperation, humanitarian aid, and neighbourhood and enlargement policies.

More than a technical exercise, this long-term budget will shape the European Union (EU)’s external action at a moment when global needs are growing and political space (and funding) for solidarity is shrinking. For Médecins du Monde (Doctors of the World), the key concern is whether the GEI will remain fit for purpose: able to respond to crises, while preserving principled humanitarian aid and sustained investment on human development and health.

The global context makes this question unavoidable. In conflicts from the Democratic Republic of the Congo and Sudan to Palestine, the Sahel and Ukraine, health systems have become targets rather than sanctuaries. Health workers are killed, detained or prevented from reaching patients; hospitals and supply chains are destroyed. These attacks do not only violate International Humanitarian Law (IHL), they dismantle, or further weaken, the everyday systems that aim to ensure human well-being and protect people from preventable disease, maternal death or untreated chronic illness. At the same time, sudden and deep cuts to Official Development Assistance (ODA) by major donors are already reversing hard-won progress, leaving millions without access to treatment, contraception or basic care. The human cost is immediate and measurable.

The MFF negotiations will shape whether EU external action is strengthened or weakened, by determining its design and governance. The European Parliament and the Council of the EU as co-legislators have a responsibility to ensure that short-term interests do not undermine long-term vision, and that private sector engagement does not replace public responsibility. If the EU stands behind the objectives of resilience, stability and shared prosperity, it must support address drivers of ill-health such as poverty or social and gender inequalities, invest in social systems, and tackle emerging and interconnected threats including humanitarian crises, food insecurity or climate change.

In this context, Médecins du Monde examines in this brief how the next EU MFF, and particularly the Global Europe Instrument, can be designed and governed to protect health, sexual and reproductive health and rights (SRHR), Mental Health and Psychosocial Support (MHPSS) and principled humanitarian, and strive towards universal health coverage, action. In doing so, it supports and aligns with CONCORD’s and VOICE’s recommendations.

1. GETTING THE FOUNDATIONS RIGHT: A PURPOSED & ACCOUNTABLE EXTERNAL ACTION

The GEI reflects a clear intention to align external action with the Union’s strategic interests. However, short-term interests must not deprioritise poverty eradication, human development nor global health. A purely transactional approach will fail to address the root causes of instability and ultimately weaken the EU’s predictability and credibility as a global partner and donor, limiting its long-term vision and impact. EU external action must remain accountable and firmly grounded in the Union’s values and legal obligations, even while aiming to advance strategic interests.

MdM’s recommendations:

Safeguard the proposed €200.3 billion budget for the Global Europe Instrument.
Realign the instrument with the EU’s Treaty obligations, include a clear and explicit reference to poverty reduction in the GEI objectives (Article 4), and clearly refer to the European Consensus on Development and SDG principles as guiding frameworks.
Make the Do No Significant Harm principle a binding safeguard across all GEI financing, prohibiting support for environmentally or socially harmful activities.

The proposed GEI architecture introduces a new logic: funds are allocated first to geographic region and then divided between programmable and non-programmable actions. While the new setup is presented as facilitating the nexus and will enable humanitarian action to access more funding, it might dilute the thematic portfolio and risks undermining focus on human development, gender equality, health and the reduction of inequalities. Flexible allocations risk, over time, deprioritizing Least Developed Countries (LDCs) and protracted or neglected crises, as funding decisions may increasingly reflect shifting annual political priorities. The GEI’s effectiveness depends on a clear long-term vision, spending targets and predictable funding, combined with flexibility to respond to crisis and emerging needs.

MdM’s recommendations:

Ring-fence 70% for programmable envelopes (for predictable and partnership-based cooperation) and 30% for non-programmable envelopes for resilience, crisis response and humanitarian aid.
Safeguard the suggested ODA target in the instrument and increase it to 93% in line with the NDICI regulation.
Reinstate minimum spending targets for Least Developed Countries (LDCs) and Fragile and Conflict-Affected States (FCAS), human development, gender equality, climate and biodiversity:
- Increase the share allocated to human development to at least 50% of ODA in the next MFF.
- Increase the share of its ODA going to FCAS to 50%, and meet the longstanding target of 0.2% of GNI to ODA to LDCs, ensuring that ODA is directed where the needs are greatest.
- Raise the proposed GEI climate and environmental spending to at least 50%, reflecting the interdependence between a stable climate, healthy ecosystems, and sustainable development.

Initiatives such as the Global Gateway may support large-scale infrastructure and investment, but they are ill-suited to the provision of public goods, such as primary health care, sexual and reproductive health services and protection, especially when these services are by nature unlikely to directly produce economic or financial benefit. Civil society organisations (CSOs) are essential to impartial humanitarian aid, especially in fragile and conflict-affected contexts, where they may be the only actors able to negotiate access and deliver care. Resilience is built by keeping local health and social protection systems running before, during and after crises. To this end, predictable funding and smart programming that enables responsible transitions are key.

MdM’s recommendations:

Ring-fence at least 15% of programmable funding under the GEI for implementation by CSOs, ensuring predictable, dedicated resources through the geographic and global pillars.
Keep direct grants central to the EU’s external action, particularly in low-income and fragile contexts and ensure direct access for local CSOs.
Apply stronger safeguards to financial instruments and private sector engagement to ensure they complement, rather than replace, civil society action.

Flexibility can enhance responsiveness, but it must not come at the expense of predictability, democratic oversight and accountability. Without clear geographic and thematic spending targets, co-legislators are effectively confined to an ex-post role. Checks and balances and transparency on how allocation decisions will be made are needed to ensure that the aid reflects and responds to the interests of the Union and partner countries. In other words, more scrutiny will only enhance the transparency and credibility of EU’s external aid, as well as alignment with needs on the ground.

MdM’s recommendations:

Remove Article 6(6) to ensure that the budgetary authority (Council and European Parliament) retains co-decision and that ODA targets cannot be simply altered through delegated acts.
Establish a clear decision-making process for the use of flexibility mechanisms to prevent them from replacing predictable, programmed investments.
Strengthen parliamentary and Council scrutiny over all reallocations and use of flexibility mechanisms, and over the mid-term review to avoid a mere implementation report.
Specific objectives and performance framework indicators should be developed in consultation with thematic experts and civil society.

2. HEALTH & GENDER EQUALITY AS PRIORITIES FOR EU’s EXTERNAL ACTION

Health cannot be delivered on a crisis-by-crisis basis. Emergency care saves lives, but without adequate preparation, prevention, vaccination, early diagnosis and long-term treatment, health systems collapse under the weight of recurring shocks. The COVID-19 pandemic exposed the global costs of underfunded health systems: countries with stronger health and social systems were better able to cope and recover, as shown by the Organisation for Economic and Cooperation Development (OECD) and the World Health Organization (WHO). EU investment in global health saves lives beyond its borders, strengthens preparedness and resilience, and protects societies from future health risks. It is both a matter of principle and foresight. It also makes economic sense: evidence shows that ODA generates significant returns, with particularly strong multipliers in areas such as contraception and maternal care, where modest investments prevent greater human, social and financial costs.

Global health and sexual and reproductive health and rights (SRHR) are a core pillar of EU external policy [1], a critical sector geopolitically and central to the EU’s open strategic autonomy. The EU has been a global health leader through initiatives such as the 2022 Global Health Strategy, Team Europe Initiative on SRHR in Africa, support to UNFPA, and the She Decides and the My Voice, My Choice initiative, but gains are fragile in an environment marked by conservative rhetorics, especially if not reinforced with sustained funding. Conflicts, increasing discriminatory laws, gender stereotypes and restrictive social norms affect individuals’ rights, choices and freedoms. Full access to quality and affordable healthcare, including SRHR (modern contraceptives, maternal healthcare, prevention of sexually transmitted infections), is a key part of building societies where everyone can live health lives, enjoy true equality and participate fully in education, work and political life. While MdM welcomes the mention of SRHR in Article 9.6 of the Global Europe Instrument, we underline that this ambition must be matched by adequate funding for gender equality, women’s empowerment and human development.

MdM’s recommendations on global health:

Elevate health-related objectives to legally binding obligations in the GEI and earmark funding for health spending, including health system strengthening, SRHR, Mental Health and PsychoSocial Support (MHPSS), epidemic preparedness, local health systems support, and nutrition.
Protect budgets dedicated to the global pillar and to geographic envelopes targeting areas with the greatest health and poverty needs, including Sub-Saharan Africa, from excessive flexibility and unpredictability.
Prevent underfunding of essential but low-commercial-return sectors, particularly in fragile contexts (access to essential medicines, vaccines, epidemics prevention and control, SHRH and MHPSS).
Maintain EU leadership in global health initiatives beyond vaccination campaigns, ensuring integrated responses to epidemics, climate-related health threats, and humanitarian crises and maintaining a strong focus on neglected areas of SHRH.

MdM’s recommendations on SRHR :

Safeguard the promotion of SRHR as part of the general principles of the instrument, recognising that it includes health services including contraception and safe abortion, education, rights, and empowerment.
Earmark funding for SRHR in the GEI as a specific objective of all geographic pillars, as well as in the global one, to ensure that funding will be allocated and projects developed at the global, regional and country level (mainstreaming it across the GEI would make it lose status, weight and actual funding opportunities, and because it must remain a priority in each geographic area).
Dedicate 85% of all EU ODA to programmes that have gender equality as one of their objectives (OECD marker G1 or G2), 20% of ODA to gender-targeted projects (OECD marker G2).
Dedicate at least 5% of ODA to supporting women led organisations (WLO), which remain critically underfunded with less than 1% of ODA directed to them.

3. A PRINCIPLED & EFFECTIVE HUMANITARIAN ACTION

The new MFF does not have a dedicated humanitarian budget line. Without a specific, ring-fenced budget, the actual amount of humanitarian funding each year could fluctuate. This unpredictability makes it difficult for humanitarian NGOs to respond effectively to sudden and protracted crises and plan interventions. Humanitarian aid is also essential to strengthen capacities for prevention, preparedness and response and early detection of health threats globally. It is important to safeguard humanitarian action, so that it is based on needs and humanitarian principles of humanity, neutrality and independence, rather than short-term political interests.

MdM’s recommendations:

Safeguard the €25 billion for humanitarian aid in the GEI, making this amount the minimum.
Safeguard the mention to the 1996 Humanitarian Regulation, which ensures the integrity of the humanitarian aid, and make sure humanitarian principles are mentioned in the GEI.
Distinguish humanitarian and ODA-related funding from other external action tools and security-related spending in order to preserve its principles, integrity and focus.
Humanitarian access must be guaranteed, not optional: the cushion should explicitly allow reinforcements of humanitarian action to respond to crises.

Conditionality-driven approaches risk undermining the effectiveness of EU cooperation by leading to human rights violations, exposing vulnerable communities to greater harm, and diverting ODA towards geopolitical and domestic priorities rather than communities’ needs and rights. These trends contribute to the politicisation of aid. In this regard, it should be noted that the ‘emergency challenges and priorities cushion’ provided for in the GEI aims to respond to „emerging crises and unforeseen needs“, and the list explicitly includes “migratory pressures”. This would in practice force humanitarian needs to compete with other priorities, potentially delaying or reducing the amount of available funding for humanitarian needs. In addition, migration-related conditionalities contravene OEDC principles to preserve the integrity of ODA. According to these principles, migration-related activities should be guided by a focus on protection and a rights-based approach, addressing the needs of forcibly displaced populations and their host communities, and aligning with partner countries’ priorities and development strategies. They should typically exclude actions whose main objective is to restrict migration, intercept and return migrants from ODA spending.

MdM’s recommendations:

Reject conditionalities on migration management, which is not embedded in international human rights law nor reflect the primary purpose of development cooperation.
If conditionality is to be maintained, a humanitarian exemption must be preserved for migration-related conditionality and clearly defined in the context of rule of law conditionality.
While the proposal rightly states that Union funding must not support actions resulting in human rights violations, it remains unclear who bears the burden of proof and how monitoring will be conducted ex ante and ex post. Clarity on these mechanisms is essential to ensure principles humanitarian action can continue to access people in need.

[1] They are an integral part of key EU external action policy frameworks and commitments, such as the 2022 Global Health Strategy, the Gender Action Plan, the European Consensus on Development, the Youth Action Plan.

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