Virginia Rodríguez Bartolomé
Policy Advicacy Coordinator, ISGlobal
The COVID-19 pandemic exposed the cracks in a fragmented global health system, with overlapping mandates, unpredictable financing, and persistent inequalities. Since 2024, this realization has driven an unprecedented cycle of reform initiatives seeking to reorder who decides, how financing works, and how international health actors coordinate.
This report maps the main initiatives in force as of September 2026, grouped into three blocks: intergovernmental processes led by the WHO and multilateral banks; regional approaches (EU, African Union, and the US “America First” strategy); and initiatives by other international actors (Lusaka Agenda, Wellcome Trust, Accra Reset, Gavi Leap). It closes with two key studies (MOPAN and HEAR CSO) that feed the debate with evidence and civil society perspectives. The aim is to offer an updated, brief, and contextualized snapshot of each initiative: what it is, where it stands today, and why it matters.
Intergovernmental initiatives
WHA Resolution on global health architecture reform and UN 80 Initiative
In May 2026, the 79th World Health Assembly (WHA) adopted a resolution launching a joint process to reform the global health architecture: a member state–led mechanism, hosted by the World Health Organization (WHO) and open to global partners, building on existing reform initiatives and elements of the UN 80 Initiative (the UN system modernization agenda). The mandate is to develop options and recommendations that respond to collective and national needs, maximizing access, impact, and equity.
To this end, a Task Force of about 24–25 members has been constituted to deliver a draft of options by November 2026 and finalize proposals in 2027, with a view to the Director-General presenting a final report to the 80th WHA (May 2027). In parallel, the WHO has published consultation documents and is gathering inputs from global and regional health institutions and civil society, although some actors have called for more formal inclusion of civil society in the process of governance. This process is the political umbrella that can align and give coherence to multiple ongoing reforms (pandemic treaty, International Health Regulations, financing, governance of initiatives), preventing each process from going its own way.
Pandemic treaty
The WHA adopted the WHO Pandemic Agreement in May 2025, after more than three years of negotiations. However, the agreement is not yet in force: the annex on the Pathogen Access and Benefit-Sharing (PABS) System, which regulates how samples and genomic sequences of pathogens with pandemic potential are shared and how benefits (vaccines, treatments, etc.) are distributed, still needs to be completed and approved.
PABS annex negotiations have been extended several times in 2026 (May, July) due to sensitive disagreements over intellectual property, benefits, and technology transfer obligations. In September 2026, the 8th meeting of the Intergovernmental Working Group was held to continue narrowing differences; the WHO plans to bring the outcome to the 80th WHA (May 2027). Only when the WHA approves the annex can the agreement open for signature and subsequent ratification; it will enter into force upon reaching 60 ratifications (30 days later). The treaty aims to close preparedness and response gaps, with an emphasis on equity, transparency, and a PABS mechanism that prevents hoarding and rewards cooperation.
Reform of the International Health Regulations
In June 2024, the 77th WHA approved a package of amendments to the International Health Regulations (IHR 2005), which entered into force on 19 September 2025 for most States Parties (some entering in 2026 after rejecting 2022 amendments). The amendments introduce the definition of “pandemic emergency” (in addition to PHEIC), commitments to equity and solidarity, faster notification algorithms for severe respiratory syndromes, an obligation for early consultation with the WHO on uncertain events, creation of a Committee of States Parties for implementation and compliance, strengthened core capacities, and a Coordinated Financial Mechanism under the WHA to develop national capacities. A National IHR Authority is also established in each country to coordinate implementation.
With the amendments now in force, the focus is on national and regional implementation, operationalization of the committee and financial mechanism, and alignment with the pandemic treaty and the joint architecture process. The IHR is the legal backbone of health security; these reforms aim to detect and respond earlier, with more equity and less opacity.
Health Works Leaders Coalition (World Bank)
Launched in October 2025 by the World Bank, the Government of Japan, and the WHO, the “Health Works” Leaders Coalition brings together ministers of Health and Finance, global health agencies, philanthropists, the private sector, and civil society to promote investments in health systems as a driver of economic growth, employment, and resilience. It is not a fund, but a platform for policy coordination and investment alignment to strengthen national health systems, a priority element underpinning all global reform proposals. At its inaugural meeting, it was announced that 21 countries would launch “National Health Compacts”: government-led agreements with reforms, investment priorities, and shared accountability to unlock resources and expand coverage of quality services. Members include Gavi, the Global Fund, Wellcome, WACI Health, the UK, and countries such as Egypt, Ethiopia, Nigeria, the Philippines, Sierra Leone, etc.
The coalition continues to operate as a political lever for the World Bank’s Health Works program, with ongoing work on national compacts and donor alignment. Its added value is connecting health and economics, and it can channel domestic and international financing toward government priorities, complementing architecture reforms with financial “muscle.”
Regional approaches
European Union and like-minded donors’ reflection process on reform of the global health architecture
The European Commission (DG INTPA) drove a reflection process with 11 EU Member States and 5 like-minded donors to identify joint reform options in a context of declining official development assistance for health. The exercise consulted nearly 500 actors and proposes reforms in five areas: normative guidance; financing and resource mobilization; market shaping and equitable access; data and surveillance; and coordination/governance.
The HISP/HERA report (March 2026) advocates making substantial progress in 2026 through an inclusive global process that articulates existing initiatives and ensures timely implementation. The EU is also participating in joint political declarations on architecture reform at health summits. This process seeks to ensure that European and like-minded donors speak with a coordinated voice, aligning their instruments with country ownership, financial predictability, and reduced fragmentation.
African Union – African high-level ministerial committee to shape global health architecture reform
In April 2026, Africa CDC launched the High-Level Ministerial Committee on Global Health Architecture Reform (AHLMC), bringing together African ministers of Health and Finance to consolidate the continent’s voice, coordinate positions, and advance a unified African platform. The committee is working on five lines: leadership and governance reform; financial sovereignty; data and digital sovereignty; product sovereignty and local manufacturing; and pandemic prevention/preparedness/response.
Among its expected outputs are an African position paper, a 2026–2030 roadmap, negotiation packages for key global processes, and a financial alignment framework (“one plan, one budget, one report”). The committee is operating as a pillar of the African health security and sovereignty agenda, with an eye on the WHA and negotiations on the treaty/IHR and financing. It gives political weight to African priorities (domestic financing, regional manufacturing, representation) and prevents the continent from arriving fragmented at global tables.
US Global health strategy- “America First”
This strategy is included in this mapping of initiatives because of the impact it is having in practice. Presented in September 2025, the “America First Global Health Strategy” reorients US health cooperation (the largest funder in absolute terms) toward five-year bilateral agreements (in the form of Memoranda of Understanding, MOUs) with recipient countries, with the stated aim of protecting the US population, strengthening health systems, and promoting partner countries’ self-reliance. The MOUs specify amounts, types, and purposes of assistance, integrated data systems, transfer of technical assistance to governments, and co-investment schemes and performance indicators.
As of April–September 2026, dozens of MOUs had been signed (more than 24 in Africa). This strategy changes the rules of the game for US health aid: less traditional multilateralism, more conditional bilateralism, and pressure for domestic financing.
International initiatives by other actors
Lusaka Agenda – Conclusions of the future of global health initiatives process
Born in December 2023 and consolidated in 2024–2025, the Lusaka Agenda is the outcome of a collaborative process (governments, donors, international organizations, civil society) to redefine the role of Global Health Initiatives (GHIs) in light of universal health coverage (UHC) and fragmentation. It proposes five strategic shifts: (1) contribute more to primary care by strengthening health systems; (2) joint approaches for equity in outcomes; (3) a catalytic role toward domestically financed public services and functions; (4) strategic and operational coherence among GHIs; and (5) coordination on products, R&D, and regional manufacturing to correct market failures.
The agenda has been referenced in G20 declarations (2025) and in African regional dialogues; Africa CDC has finalized a monitoring and accountability framework. It offers a compass for GHIs (Global Fund, Gavi, etc.) to align their investments with national priorities and financial sustainability.
Wellcome Trust – From Rethinking to Reform: The Way Forward for the Global Health System
In March 2026, Wellcome published a synthesis paper capturing reflections from five regional dialogues (August–November 2025) with participants from over 114 countries on global health reform. The report calls for clarifying and simplifying organizational roles, shifting power toward regions and low- and middle-income countries, and giving civil society more weight in decision-making and accountability; it also urges strengthening the WHO’s core functions (normative, health security, convening) and reforming ODA to prioritize the poorest countries and accelerate the transition from aid dependence to domestic financing.
Wellcome is organizing high-level meetings to translate the dialogues into action agreements and is participating in the Health Works Coalition. It brings an independent, globally consulted vision that connects with the WHO’s joint process and demands for sovereignty and governance.
Accra Reset – Resetting global development cooperation for a post-dependency world
Launched by Ghana’s President, John Dramani Mahama, on the margins of the UNGA (September 2025) and expanded at Davos (January 2026), the Accra Reset is a roadmap to transform development cooperation: moving from aid dependence to regionally led “spheres of prosperity,” with local industrialization, fair trade terms, and financing aligned to countries’ own priorities. Within this initiative, health has moved from being its seed to a paradigmatic area to test the proposal: it calls for new financing and business frameworks, an emphasis on regional manufacturing of vaccines/medicines, and alignment between domestic resource mobilization and external co-investment.
The initiative is in its second phase, having established its governance bodies with a presidential council and working groups seeking to publish concrete recommendations (in October 2026) and articulate regional “Prosperity Spheres.” It connects health and economic development from a Global South sovereignty perspective, influencing the discourse on financing and governance.
Gavi Leap – Transforming the vaccine alliance through simplicity, transparency and synergy
“Gavi Leap” is Gavi’s transformation program for the 2026–2030 strategic period (Gavi 6.0), designed to radically simplify operations, increase transparency, and boost synergies with other actors. It is structured around five pillars: (1) Primacy of recipient countries: greater country agency, simplified operations, and consolidation of 8 funding windows into a single budget envelope aligned to the strategic cycle; investment in African vaccine manufacturing; agile support in fragile contexts; and sustainable financing via multilateral banks. (2) Tuning the “engine”: changes in the Secretariat to adjust and reduce expenditures. (3) Strengthening partnerships: synergies with the Global Fund and the Polio Eradication Initiative. (4) Entering the intelligence era: technology/AI solutions. (5) Steering the future of immunization.
Gavi has begun sending five-year vaccine budgets (guaranteed and discretionary) to its 56 recipient countries, with greater visibility and flexibility, and is advancing simplification of grant management. It reduces administrative burden, gives countries financial predictability, and aligns with demands for sovereignty and simplification of the architecture.
Studies and Analyses
MOPAN – Global Health Insights Study mapping of organisational mandates against future priority health functions
In May 2026, MOPAN (Multilateral Organisation Performance Assessment Network) published the first of a series of three reports on the global health architecture, titled Mapping of Organisational Mandates Against Future Priority Health Functions. The study maps the mandates and practices of nine key multilateral organizations (WHO, UNICEF, UNFPA, World Bank, Global Fund, Gavi, GFF, Pandemic Fund, and Unitaid) against the six priority functions a reformed architecture should perform: health security and pandemic preparedness; health systems strengthening and primary care; maternal, child, and reproductive health; communicable diseases (HIV, tuberculosis, malaria); market shaping and access to products; and data, surveillance, and accountability.
The report’s central question is not whether each individual mandate is adequate in itself (most are), but whether the current configuration of mandates is capable of delivering those six functions coherently, equitably, and efficiently. The conclusion is clear: “not yet.” The expansion of mandates driven more by donor priorities than by system needs, coupled with insufficient collaboration and alignment among organizations (especially at country level), has generated overlaps and likely inefficiencies in the delivery of priority functions.
Among the key findings, the study highlights that: (i) global financing and technical support are often misaligned with national priorities, limiting country ownership and long-term planning; (ii) regional institutions remain underutilized, despite their potential to improve coordination, representation, and collective action; (iii) fragmented governance and donor-dependent, short-term financing weaken system coherence and sustainability; (iv) gaps in digital and data systems hinder timely decision-making, coordination, and accountability; and (v) primary health care is consistently identified as the most viable foundation for building resilient, integrated systems.
This report is conceived as a practical contribution to reform discussions and to the WHO’s proposed “joint process,” by providing an empirical basis to identify gaps, interdependencies, overlaps, and areas requiring clearer role delineation in the system. MOPAN products are already cited in donor discussions and in reflection processes such as that of the EU and like-minded donors, providing comparable metrics on efficiency and alignment with country priorities. Without hard data, reform becomes rhetoric; MOPAN provides indicators to prioritize changes and measure progress.
HEAR CSO – Reimagining Global Health Architecture: Global Civil Society on the Future of Global Health Architecture
HEAR CSO (Health Architecture Reimagined – Civil Society Organizations) is a consortium launched in September 2025 that has convened around 140 civil society organizations and affected communities across seven regions to map the future of the global health architecture from a rights, equity, and community ownership perspective. Between October 2025 and April 2026, the consortium held seven regional consultations and a global survey with actors from over 90 countries, with results synthesized in the report Global Civil Society on the Future of Global Health Architecture, published in May 2026.
The report starts from a shared observation: the system has achieved important advances, but faces serious structural pressures. In the global survey, 93.7% of respondents consider that the financing crisis is putting hard-won gains at risk; 90.2% note that agreements intended to promote equity in global health are often not implemented, funded, or prioritized; and 87.0% believe that global health governance has not evolved at the pace of changes in who pays, decides, and implements. In response to this diagnosis, the reform priorities generating the most consensus are: strengthening domestic financing for health (69% mark it as a top priority), developing financing approaches that work in middle-income countries and mixed regions (55%), strengthening regional coordination, broadening the definition of global public goods, and investing in community-led, nationally anchored systems.
On the basis of this evidence, HEAR CSO has issued public positions on the WHO’s proposed “joint process” for architecture reform. When the WHO published its final proposal for the joint process in May 2026, the consortium denounced that the final version removed civil society and affected communities from leadership roles in the governance structure (Task Force), unlike institutions such as the Global Fund, Gavi, or Unitaid. In response, HEAR CSO called on Member States, ahead of the 79th WHA, to guarantee at least two seats on the Task Force for people living with and affected by health inequities and for civil society, as well as additional seats reflecting existing CSO representation in global health institutions, with priority for leadership from low- and lower-middle-income countries; they also requested a dedicated, resourced process to engage affected communities, co-designed with their meaningful participation, and clear criteria to minimize the influence of actors with financial rather than lived stakes in global health.
HEAR CSO remains active with community-driven conversations and alliances with regional groups, and its findings are already cited in reform debate spaces (including pre-WHA dialogues and forums such as IAS 2026), as input to ensure reforms do not ignore the most affected populations. It introduces a rights and equity perspective that is often left out of technical tables, reminding us that the architecture must first serve those who need it most and that communities must not only be included, but empowered to lead.
