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Virginia Rodríguez Bartolomé
Advocacy Coordinator at ISGlobal
March 2026
Global health can no longer be understood as a predominantly academic or development field, defined by epidemiological indicators, relatively stable scientific consensus or cooperation projects in the health sector. It has become a space of strategic contestation where security interests, geopolitical rivalries, trade tensions and high-stakes normative debates converge. Rather than ushering in a phase of strengthened cooperation, the gradual exit from the acute phase of the COVID-19 crisis has coincided with an acceleration of centrifugal dynamics that are reshaping the international order and, with it, the global health governance ecosystem.
We are facing a “polycrisis” in which armed conflicts, intensifying competition between major powers, the climate emergency, migratory pressures, the fiscal deterioration of many states and the erosion of consensus around multilateralism and the international order of the second half of the 20th century converge. Meanwhile, lower-income countries are confronting the direct effects of a financing crisis that threatens the sustainability of health systems highly dependent on external aid.
In this context, health has shifted from being primarily conceived as a global public good to becoming a tool of influence, an element of national security and a bargaining variable in strategic alliances. The result is a more fragmented, transactional and less predictable environment.
1. Erosion of multilateralism and weakening of normative consensus
For decades, the system of multilateral norms and institutions has provided a relatively stable framework for health cooperation, grounded in principles such as equity, human rights and international solidarity. Instruments such as the 2030 Agenda for Sustainable Development have served as a shared roadmap, integrating health within a broader vision of inclusive development.
However, this normative consensus is undergoing a period of accelerated erosion. Ideological polarisation has directly affected sensitive areas such as sexual and reproductive health, gender equality and comprehensive health education. Technical debates have taken on an increasingly political dimension, making agreements in multilateral forums more difficult and slowing progress that once seemed well established.
In this context, the World Health Organization (WHO) is attempting to sustain its regulatory authority and coordinating role under constant political pressure and with a structurally fragile financing model. While states formally recognise its centrality, in practice operational and financial leadership has shifted towards vertical funds, public–private partnerships and regional mechanisms operating with their own agendas and priorities.
Actors such as Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria have demonstrated an ability to mobilise resources and deliver concrete results, enabling unprecedented reductions in maternal and child mortality, as well as deaths caused by HIV and malaria. However, their proliferation has contributed to a fragmented architecture in which systemic coherence depends on coordination mechanisms that are not always robust.(1) The result is an ecosystem in which multiple centres of decision-making coexist without a unified strategic direction, complicating comprehensive responses to interconnected challenges such as climate change, antimicrobial resistance or protracted humanitarian crises.
(1) Rodríguez V, Aguilar C, Corkal A, Fraga A, Mascareñas M, Fanjul G and GarcíaVaz C. How do global health initiatives contribute to strengthening health systems? Barcelona Institute for Global Health (ISGlobal). ISGlobal Analysis Paper. June 2025.
2. Competing models: US retrenchment and China’s strategic projection
The international health architecture today clearly reflects the rivalry between competing visions of global power. In recent years, US foreign policy has oscillated between multilateral engagement and tendencies towards retrenchment and the pursuit of national interest associated with the “America First” approach.(2,3) The mere threat of disengagement from WHO, along with cuts or uncertainty surrounding funding channelled through USAID, has sent signals of volatility that have eroded the system’s predictability.(4)
Flagship programmes such as PEPFAR, which for two decades has been a cornerstone in the fight against HIV, have become exposed to domestic political debates that go beyond the health sphere. This volatility affects countries highly dependent on external funding to sustain critical interventions against HIV (5), tuberculosis and malaria (6), creating risks of reversing hard-won progress.
In parallel, China has deployed a form of health diplomacy integrated into its broader geoeconomic strategy. Through the so-called Health Silk Road,(7) linked to the Belt and Road Initiative,(8), Beijing has provided medical equipment, vaccines and hospital infrastructure across multiple regions. This model is presented as pragmatic and respectful of national sovereignty, as it does not include explicit governance conditionalities.(9,10)
However, the underlying logic is fundamentally transactional. The provision of infrastructure and supplies may create financial or technological dependencies and is not always embedded within long-term national health system strengthening strategies.(11) Competition between these models — one rooted in normative tradition but subject to domestic political fluctuations, the other more instrumental and geoeconomic — introduces additional tensions into global health governance.
(2) Collinson E et al. US Congress Says Yes to Foreign Aid—Now Comes the Hard Part. Center for Global Development. 16 January 2026.
(3) Cullinan K. US Ties Global Health Aid to Data Sharing on Pathogens – Undermining WHO Talks. Health Policy Watch. 7 November 2025.
(4) Jennings S, García-Vaz C, Diago-Navarro E, Innocenti L and Fanjul G. Trump’s Earthquake and its Aftershocks: How the Implosion of the Global Health System Increases Inequality, Weakens Global Governance and Threatens Us All. Barcelona Institute for Global Health (ISGlobal). Policy Paper. July 2025.
(5) Agúndez L, Rodríguez V, García-Vaz C, Marín C and Fanjul G. Decades of progress at a crossroads: how cuts and inaction threaten the fight against HIV. Barcelona Institute for Global Health (ISGlobal). Series: Infectious Diseases. November 2025.
(6) García-Marín C, Rodríguez V, García-Vaz C and Fanjul G. A decade of stagnation: reinforcing commitment to avoid setbacks in the fight against malaria. Barcelona Institute for Global Health (ISGlobal). Series: Infectious Diseases. November 2025.
(7) Ren M. Global health and the Belt and Road Initiative. Global Health Journal. Vol. 2, No. 4. 24 September 2019.
(8) Lo C and van de Pas R. China’s Global Health Diplomacy: Possibilities and limitations for cooperation. China Knowledge Network (CKN) / Maastricht University. July 2023.
(9) Rudolf M. China's global health diplomacy: revisiting Beijing's pre- and post-COVID-19 outreach efforts. Friedrich-Ebert-Stiftung. Series: Peace and Security. October 2022.
(10) Think Global Health. China's Foreign Policy and Global Health Leadership. Council on Foreign Relations. 2024.
(11) Husain L and Sullivan R. Escaping the Kindleberger Trap: What Role for China in Reshaping Global Health for a Low-Cooperation World?. Center for Global Development. 9 April 2025.
3. The European Union: normative leadership under strategic pressure
The European Union has sought to position itself as a normative actor in this context, promoting a European Global Health Strategy that combines health security, system strengthening and the promotion of the right to health. The development of the “European Health Union” following the pandemic strengthened internal preparedness and coordination instruments, and projected an image of commitment to multilateral rules.
However, this ambition faces structural constraints. The strategic autonomy agenda, driven by the war in Ukraine and growing geopolitical rivalry, prioritises industrial resilience, energy security and defence.(12,13) In this shift, global health risks becoming subordinated to considerations of competitiveness or border control.
Moreover, several traditional European donors have reduced their Official Development Assistance, redirecting resources towards defence and domestic responses to the energy crisis. This contraction does not necessarily reflect an ideological rejection of multilateralism, but rather fiscal constraints and security priorities.(14) However, its practical effect is the weakening of the bloc that has historically defended health under a framework of social justice and organised solidarity.
(12) Draghi M. "The future of European competitiveness: A competitiveness strategy for Europe", September 2024.
(13) Letta E. "Much more than a market: Speed, Security, Solidarity - Empowering the Single Market to deliver a sustainable future and prosperity for all EU citizens", April 2024.
(14) Olivié I. The end of development aid? Elcano Royal Institute. ARI 48/2025. 27 March 2025.
4. Global South: towards an agenda with greater agency
Latin America, after being one of the regions hardest hit by COVID-19, is now emerging as a testing ground for debates on autonomy and health sovereignty. The experience of vaccine diplomacy revealed both structural vulnerability and the region’s capacity for coordination in critical moments.
The region is calling to move from a model of dependency towards one with greater normative, productive and technological capacity of its own, reducing exposure to supply chain disruptions and to stockpiling dynamics by advanced economies. This demand is shared by many countries in Africa and Asia, which question the logic of aid dependency and the proliferation of fragmented projects driven by external donors.
In Africa, the debate on health sovereignty takes on a particularly strategic dimension.(15,16) Health systems historically financed to a large extent through official development assistance are now facing the direct impact of funding cuts and the redirection of cooperation flows. This contraction not only strains the sustainability of essential programmes, from HIV and malaria to immunisation, but also exposes the structural vulnerability resulting from models overly dependent on external funding and vertical architectures insufficiently integrated into national systems.
At the same time, African states, acting through the African Union, have intensified their demand for greater voice and decision-making power in global health governance. Continental initiatives aimed at the financial sustainability of health systems, local vaccine production, regulatory coordination and joint negotiation with international partners reflect a broader strategy of geopolitical repositioning.(17,18,19) Rather than passive recipients of aid, African countries are seeking to redefine their relationships with the Global North and traditional donors on the basis of shared responsibility, technology transfer and alignment with national and regional priorities.(20,21)
The Global South is calling for international cooperation to align with national health plans, strengthening public infrastructure and institutional capacity, rather than imposing short-term agendas. Coherence, predictability and national ownership have become central conditions for a more balanced relationship between donors and recipients.
(15) Amref Health Africa. Africa’s Pathway to Health Sovereignty. CNBC Africa. 24 September 2025.
(16) Pate M A. Building Africa’s Health Sovereignty: From Dependence to Partnership. Health Policy Watch. 11 November 2025
(17) Africa CDC. "Africa’s Health Financing in a New Era: Safeguarding Africa’s Health", April 2025.
(18) Africa CDC. "Financing Africa’s Health Security and Sovereignty: A Health Financing Reform Handbook for African Union Member States", 10 January 2026.
(19) Africa CDC. "The Durban Promise: Moving Toward Self-Reliance to Achieve Universal Health Coverage and Health Security in Africa", 25 October 2025.
(20) Presidency of the Republic of Ghana. "STATEMENT: African Health Sovereignty in a Reimagined Global Health Governance Architecture", 3 August 2025.
(21) Cullinan K. African Countries Affirm Support for Multilateral Pandemic Agreement Amid Pressure to Make Bilateral Deals with the US. Health Policy Watch. 11 November 2025.
5. Debates and reforms in the global ecosystem: equity as a guiding principle
Reforming the international health architecture is not merely a technical exercise. It involves redefining priorities, redistributing power and clarifying responsibilities in a context of scarce resources and growing demands. These are the key debates to be addressed in this process.
- Financing of national systems and complementarity of international aid
- Governance and redistribution of decision-making power
- From national security to global human security
- Health sovereignty and strategic autonomy
- The health–climate nexus as a structural axis
- Gender equality, rights and health in a context of normative regression
6. Spain in global reconfiguration: coherence and values
In an international context marked by shrinking financial contributions, the retrenchment of some traditional donors and growing challenges to multilateral frameworks, Spain has chosen to take a proactive role in defending and renewing global health. Rather than adopting a reactive stance, the country has consolidated a track record of sustained commitment to its partners, shaping a foreign policy that positions health as a strategic vector for cooperation, stability and international projection. The Spanish Global Health Strategy 2025–2030 reflects this approach, reaffirming a framework grounded in rights, equity and the structural strengthening of health systems.
By strengthening its engagement with the World Health Organization, Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, Spain is not only increasing its financial contribution at a critical moment, but also sending a clear political signal in support of multilateral health cooperation. This commitment comes at a time when other actors are reducing their engagement or prioritising strictly national approaches, reinforcing Spain’s position as a reliable and predictable partner.
This leadership is built on coherence between discourse and practice: advocating for equitable access to health technologies, supporting the strengthening of public systems, and promoting horizontal partnerships with Latin America and Africa. Within this framework, Spain acts as a bridging node between regions, helping to reduce gaps and sustain inclusive governance spaces.
Value-based leadership is not opposed to the defence of national interests; rather, it integrates them into an interdependent vision of security and development. In a globalised world, the resilience of one’s own health system depends on the strength of the most vulnerable systems. Investing in global health is therefore a strategic investment in stability, international legitimacy and shared wellbeing.
