Reforming the Global Health Architecture in a Fragmented World

A Reform under Pressure

The global health architecture faces a paradox: the need for international cooperation has never been more evident, yet building it has never been more difficult. Transnational health threats (pandemics, antimicrobial resistance, climate change, conflicts, forced displacement and disinformation) cannot be managed effectively by nation-states acting alone. Yet, the system charged with responding to them faces an unprecedented combination of institutional fragmentation, geopolitical competition, a funding crisis and declining trust in multilateralism.

COVID-19 exposed the consequences of these weaknesses. The lack of effective mechanisms to ensure equitable access to vaccines, diagnostics and treatments showed that health interdependence does not automatically translate into solidarity. The pandemic also laid bare the gap between the World Health Organization’s (WHO) formal authority and the political, financial and operational resources at its disposal.

Since 2024, proposals for reform have emerged at a particularly rapid pace. Some have come from WHO-led intergovernmental processes; others from multilateral development banks, regional organisations, global health initiatives, philanthropic foundations and civil society networks. An updated mapping of these initiatives identifies three main arenas of change: multilateral processes; regional approaches, (particularly focused in the African Union, the European Union and the United States); and proposals advanced by non-state actors, including the Lusaka Agenda, Wellcome Trust, Accra Reset and Gavi Leap.

The problem is not a lack of ideas. It is the difficulty of translating them into a coherent framework that is politically legitimate and financially viable. Reform must address two urgent needs at once: preventing the immediate deterioration of essential programmes, particularly in countries highly dependent on aid, and correcting the structural failures that have produced dependency, duplication of effort and imbalances of power. This dual task lies at the heart of the debate: preserving the existing system is not enough, but neither can it be reformed without regard for the human and political consequences of a disorderly transition.

1. From a Network of Initiatives to a Governable System

Health has historically been one of the most enduring areas of cooperation among states. Cross-border threats prompted the development of rules, surveillance mechanisms and international agreements long before global health became an established field of policy. Since its founding in 1948, the World Health Organization (WHO) has occupied a distinctive position as the directing and coordinating authority on international health.

Its mandate has three dimensions. First, a normative and regulatory role, expressed through technical standards, recommendations and legal frameworks such as the International Health Regulations (IHR). Second, a coordinating role in emergencies. Third, a role in providing technical support to states as they strengthen their health systems, expand universal health coverage and develop surveillance and response capacities.(1)

From the 1990s onwards, however, the global health architecture began to change. The growth of disease-specific funds, public–private partnerships, bilateral agencies, foundations and specialised organisations made it possible to mobilise resources on an unprecedented scale. Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Unitaid; the Pandemic Fund; the Global Financing Facility; and other disease-specific initiatives contributed to remarkable advances in vaccination, HIV, tuberculosis, malaria, and maternal and child health.

Their effectiveness was closely tied to specialisation. Concentrating resources on clearly defined problems makes it easier to set objectives, measure results and mobilise political support. But the same logic has produced a fragmented architecture: multiple actors operate in the same countries under different mandates, timelines, indicators, disbursement procedures and accountability systems. National health authorities end up managing a portfolio of projects rather than directing an integrated health policy.

MOPAN’s study of nine multilateral organisations and six priority health functions (health security, health-system strengthening, maternal, child and reproductive health, communicable diseases, access to health products, and data and accountability) confirms this gap. The problem is not necessarily that individual mandates are inadequate, but that the organisations, taken together, are still unable to fulfil these functions coherently, equitably and efficiently. Overlaps, gaps and weak coordination at country level persist.

The pandemic intensified this contradiction. Gavi and the Global Fund were essential to sustaining interventions in low-income countries, while COVAX sought to organise a multilateral response to vaccine distribution. Nevertheless, advance purchases of doses by wealthy countries, together with constraints on production and intellectual property, exposed the limits of a system that could mobilise resources but could not ensure an equitable response.

The current crisis is compounded by the decline in international funding. The United States’ withdrawal from the WHO and the dismantling of USAID have disrupted the financial foundations of health cooperation. The new US strategy, based on five-year bilateral agreements and co-investment requirements, marks a shift away from traditional multilateralism towards a more transactional model of aid.

This US shift has not occurred in isolation. France, Germany and the United Kingdom have also reduced their aid budgets while increasing domestic allocations to defence and security. ISGlobal estimates that, if recent funding levels are not restored, the combined withdrawal of these three donors could result in more than 11.5 million additional preventable deaths by 2030. This figure should be read as an estimate of the potential scale of the impact, not as an exact causal prediction.(2)

(1) Rodríguez Bartolomé V. WHO: A normative and coordinating pillar of the global health system Barcelona: Instituto de Salud Global de Barcelona (ISGlobal); 2026.

(2) García-Vaz C, Fanjul G, Agúndez Rodríguez L, Rasella D, et al. Rupture, Not Transition: The Retreat of European Aid, the Human Cost of Global Health Cuts, and the Fight for a New System of International Cooperation. Barcelona: Instituto de Salud Global de Barcelona (ISGlobal); 2026.

2. What Needs to Change: Shared Priorities and Redistribution of Power

The first distinction to make is between a funding emergency and systemic reform. Countries whose health systems depend heavily on aid need immediate resources to maintain vaccination programmes, treatments, staffing, surveillance and primary health care. But covering budget shortfalls year after year does not resolve structural vulnerability. Reform must create the conditions for aid to be catalytic and temporary, rather than the permanent foundation of essential state functions.

The first objective is coordination. The Lusaka Agenda calls for global health initiatives to make a stronger contribution to health-system strengthening and primary health care, adopt shared approaches to equity, act as catalysts for domestic financing, improve their operational coherence, and coordinate market shaping, research and regional manufacturing. Its significance lies in translating criticism of fragmentation into operational principles that the major global health partnerships can apply.

Coordination, however, should not be confused with simply reducing the number of actors. Each organisation brings specific capabilities: procuring and distributing vaccines, financing responses to particular diseases, generating knowledge, responding to emergencies or mobilising capital. The question is how these organisations relate to one another and who sets the overarching priorities.

The second objective, therefore, is to strengthen the leadership of recipient countries. Country ownership does not mean consulting a ministry about a project designed elsewhere. It means that the government defines an integrated health plan, a budget, a results framework and an accountability system with which international partners align. The principle could be summed up as “one plan, one budget and one monitoring framework”.

The Health Works coalition, launched by the World Bank, Japan and the WHO, seeks to move in this direction through National Health Compacts. It is not a fund but a platform for aligning reforms, domestic investment, external financing and accountability around country-defined priorities. Its value lies in connecting institutional reform to a stronger financial and political foundation, as efforts in countries such as Ethiopia and Nigeria are beginning to illustrate.

The third objective is to clarify governance functions. The WHO must retain its normative authority, its convening role and its responsibility for producing global public goods. But the division of responsibilities among the WHO, UNICEF, UNFPA, multilateral development banks, Gavi, the Global Fund, the Pandemic Fund and regional institutions such as the Pan American Health Organization (PAHO) needs to be more explicit. The architecture does not necessarily need a single operational centre, but it does need a normative and coordinating centre with sufficient capacity to prevent donor priorities from displacing national health priorities.

This raises a contested question: the future of the WHO. Some analysts advocate a “leaner” organisation focused on regulation, health security and global public goods, with a limited operational presence in countries. Others argue that normative legitimacy requires a presence at national and regional levels: international standards only become meaningful when they can be translated into policies adapted to specific contexts. The WHO’s own reform process appears to favour system-wide leadership rather than retrenchment, seeking to align the different actors with national priorities.(3)

The fourth objective is to redistribute power. The current architecture still reflects, to a considerable extent, the financial capacity of donor countries and the influence of institutions in which some countries hold larger voting shares. Yet the countries bearing the greatest burden of health crises cannot be confined to implementing decisions made elsewhere.

The African Union has established a High-Level Ministerial Committee to develop a common position around five priorities: governance, financial sovereignty, data and digitalisation, regional production of health products, and pandemic preparedness. Its proposal for an African framework for financial alignment—one plan, one budget and one report—links the demand for representation to practical reform of aid.

In Latin America and the Caribbean, PAHO’s experience and its Revolving Funds show that regional approaches can increase bargaining power, improve procurement and generate solutions tailored to local needs. The region also calls on financial institutions to move beyond criteria based solely on income per capita and use multidimensional measures of vulnerability. The exclusion of middle-income countries with deep inequalities is one of the most visible shortcomings of the current system.(4)

Civil society participation is another dimension of legitimacy. The HEAR CSO consortium, which consulted organisations in around 90 countries, reports that 93.7% of respondents believe the funding crisis threatens the gains achieved, while 87% think governance has not kept pace with changes in who pays, makes decisions and implements programmes. Its proposals call for meaningful representation of affected communities, not merely a consultative role.

(3) Rodríguez Bartolomé V. WHO: A normative and coordinating pillar of the global health system Barcelona: Instituto de Salud Global de Barcelona (ISGlobal); 2026.

(4) Rodríguez Bartolomé V, Agúndez Rodríguez L.The dilemma facing Latin America and the Caribbean in the restructuring of the global health system Barcelona: Instituto de Salud Global de Barcelona (ISGlobal); julio de 2026.

3. The Financing Challenge: Transition, Autonomy and Public Goods

Financing is where ambitions for reform encounter their most significant challenges. States bear the primary responsibility for financing health systems, but many low-income countries lack the fiscal space to do so. The pandemic increased debt, slowed growth and diverted resources towards emergency responses. Under these conditions, calling for more domestic financing is insufficient unless it is accompanied by debt relief, economic growth and predictable external support.

Reform must operate across three time horizons. In the short term, it must prevent disruptions to essential programmes. In the medium term, it must align aid with national plans and make funding more predictable. In the long term, it must support domestic resource mobilisation and greater autonomy for health systems.

The WHO is a prime example. Around 80% of its budget comes from earmarked voluntary contributions, limiting its ability to set priorities independently and respond swiftly. Its goal is for assessed contributions to cover 50% of its base budget by 2030. The case for this is not merely institutional: a better-funded WHO can provide standards, surveillance, coordination and preparedness that no state could deliver alone.

Financial diversification should include innovative instruments, but innovation must not become a substitute for public commitments. Debt-for-health swaps, results-based financing, guarantees, matching funds and the blending of public and private resources can increase the funding available. They must, however, meet requirements for additionality, transparency, debt sustainability and alignment with national priorities.

Multilateral development banks have a particularly important role to play. They can provide financing on more favourable terms, coordinate domestic and external investment, support regional manufacturing and facilitate reforms to procurement and regulatory systems. They can also help close the financing gap facing middle-income countries, which are excluded from many grants because of their income classification despite continuing to face substantial health vulnerabilities.

Mobilising private capital is essential, but it requires caution. The private sector can contribute to research, manufacturing, logistics and digitalisation, but it must not determine global health priorities on its own. Affordable access, contractual transparency and accountability must be built into arrangements from the outset.

Financing must also protect global public goods from a transactional approach. Developing vaccines in advance, sustaining surveillance networks, developing antibiotics for neglected diseases and maintaining rapid-response capacities generate benefits that cannot be confined to the country that pays for them. If cooperation is structured as a conditional bilateral exchange, these functions will remain underfunded.

Europe’s experience illustrates the risk. Aid cuts not only threaten specific programmes; they make multilateral funding less predictable, may encourage other donors to withdraw and can shift the agenda towards national security priorities. Replacing cooperation with military spending is not neutral from a security perspective either: fragile health systems increase vulnerability to epidemics, conflicts and displacement.

The transition must be planned, gradual and financed. Otherwise, “autonomy” risks becoming a politically acceptable term for abandonment.

(5) Rodríguez Bartolomé V. WHO: A normative and coordinating pillar of the global health system Barcelona: Instituto de Salud Global de Barcelona (ISGlobal); 2026.

4. A Contested Reform: Geopolitics, Regionalisation and Common Rules

Reforms are taking place in a geopolitical environment that makes agreement difficult. Global health has become an arena of strategic competition: states increasingly link it to national security, diplomatic influence, industrial autonomy, access to markets and control over data. The pandemic reinforced this trend, particularly in relation to vaccines, supply chains and critical technologies.

The intergovernmental process launched by the World Health Assembly in 2026 aims to provide a common political framework. The resolution on reforming the global health architecture establishes a working group tasked with developing options and recommendations, with a draft expected in November 2026 and final proposals for the 2027 World Health Assembly. Its most important role is not necessarily to create a new organisation, but to align processes that have so far advanced separately.

These include the WHO Pandemic Agreement, amendments to the International Health Regulations (IHR) and reform of the organisation’s financing. The pandemic agreement was adopted in May 2025, but the annex on the Pathogen Access and Benefit-Sharing System remains to be completed. Disagreements over sample sharing, intellectual property, technology transfer and the distribution of benefits show that equity is not an abstract principle: it affects the distribution of industrial capacity and economic power.

The IHR amendments, in force for most states since September 2025, introduced the category of pandemic emergency, new notification obligations, national coordination authorities and a coordinating financial mechanism. The challenge is no longer simply to negotiate rules, but to implement them. The effectiveness of the IHR will depend on whether countries have the necessary capacities (and the funding to develop them).

At the same time, regional approaches are gaining prominence. Africa is calling for sovereignty over manufacturing, data and financing. Latin America and the Caribbean are seeking to strengthen collective mechanisms and develop a common position. The EU is trying to coordinate its member states and like-minded donors on financing, access to health products, data and governance. The United States, by contrast, is pursuing a bilateral strategy that could strengthen some national capacities but also weaken multilateral coordination and increase conditionality.

These approaches are not necessarily incompatible. A more regionalised system can complement the WHO rather than replace it. Regional institutions are better placed to assess needs, pool demand, produce health goods and adapt standards to local contexts. The WHO can provide universal legitimacy, common standards and cross-border coordination. Problems arise when regionalisation becomes competition between blocs, or when bilateral arrangements displace shared mechanisms.

The central risk is that the proliferation of reform processes will reproduce the very problem they are meant to solve. Creating another platform to coordinate existing platforms may add to institutional complexity without improving decision-making. Every reform proposal should therefore be tested against a simple question: does it reduce fragmentation, redistribute power, make financing more predictable or strengthen countries’ capacities? If it does none of these things, it is likely to add complexity rather than resolve it.

Conclusions: Reform without Abandonment

The global health architecture does not need to return to the past. The previous model delivered historic gains, but it also produced dependency, unequal distributions of power and fragmentation that COVID-19 made impossible to ignore. The answer is neither to preserve existing institutions unchanged nor to replace them with a patchwork of bilateral agreements.

Reform should rest on five principles:

• A WHO with normative authority, coordinating capacity and more independent financing.
• Country-led national health systems, with plans, budgets and results frameworks to which external partners align.
• Regional institutions with greater political, financial, regulatory and manufacturing capacity.
• Diversified, predictable financing that combines domestic resources, international cooperation, multilateral development banks and innovative instruments without shifting excessive risks onto vulnerable countries.
• Meaningful participation by communities and civil society in shaping and evaluating policies.

The immediate priority is to prevent the funding crisis from destroying capacities built up over decades. The transition towards greater autonomy cannot be financed through abrupt cuts. Countries most dependent on aid need time, financial relief and support to mobilise domestic resources. Donor withdrawal is not reform: it is a disorderly transfer of human and political costs.

The process under way at the WHO offers an opportunity to bring disparate initiatives into a more coherent framework, but it will be legitimate only if countries of the Global South, regional institutions and affected communities are meaningfully included. Reform must do more than redistribute functions among international organisations; it must redistribute decision-making power.

The decisive question is what we mean by health security. If it is reduced to protecting wealthy countries from external threats, it will entrench an unequal, defensive architecture. If it is understood as a shared responsibility (encompassing primary health care, access to technologies, rights, data, financing and manufacturing capacity)it could become the foundation of a renewed multilateralism.

The system is changing, whether or not there is global agreement on the direction it should take. One possibility is that cuts, geopolitical competition and bilateral conditionality will shape the transition. The other is to turn the crisis into deliberate reform: less fragmented, more responsive to regional needs, financially sustainable and politically legitimate. This is not a choice between cooperation and sovereignty, but a question of building cooperation that enables countries to exercise health sovereignty effectively and in solidarity with others.