Global health series: Centering countries within global health architecture transformation

Introduction

Ongoing calls for reform of the global health architecture (GHA) have gained momentum in recent months due to major shifts in geopolitical priorities. Budget cuts, resulting in declining ODA flows, as well as tightening fiscal space in many low- and middle-income countries (LMICs), have once again brought into focus issues of fragmentation and inefficiencies within the existing architecture. In addition, global emergencies, notably the COVID-19 pandemic, have exposed structural weaknesses within the system, as well as the inequity in stakeholder representation at decision-making tables. The Lusaka Agenda, released at the end of 2023 and developed through multi-stakeholder processes, called for reforms to ensure better alignment of systems, harmonization of activities, reduced fragmentation, and increased country-driven leadership.

Reform of the global health space is therefore at a pivotal juncture and has been a central point of discussion at key global health moments throughout 2025. Part of a series, this introductory piece explores the major themes within calls for architecture reform.

Key terms

The global health architecture refers to the system of principles, agreements, structures, and actors working to improve health worldwide. The architecture operates across multiple levels, including global functions (e.g., norms, standards, global preparedness and surveillance, financing, market shaping, pooled procurement), regional functions (e.g., context-dependent technical assistance), and national functions (e.g., country led planning and delivery).

(GHI) refers to organisations that integrate the efforts of stakeholders around the world to mobilise and disburse funds to address health challenges, and do so by supporting the implementation of health programmes in low- and middle-income countries.

Global public goods are benefits that are nonexcludable and nonrival, available to everyone without reducing others' access, and require international coordination and financing to avoid undersupply. In health examples include pandemic surveillance and early warning systems, internationally agreed norms and standards (e.g., health regulations and guidelines), and open access research and data, while beyond health they include the metric system and climate stability.

What is driving global health reform?

Severe pressures on the current global health architecture have exposed and intensified some long-standing challenges. Three critical issues shape current debates:

Funding instability

Declining ODA and unpredictable funding streams have put the long-term survival of major health programs at risk. Volatility in funding has immediate effects on service delivery in low- and middle-income contexts, with disruptions occurring as soon as donors pause or cut funds. OECD analysis warns that financing global public goods should come from diversified, predictable sources beyond ODA, noting ODA for health is projected to fall back to around 2020 levels by 2027. This decline is already being seen, as the US, UK, Germany, and France have cut ODA over the past two years. This decline is being driven by a mix of factors: the fiscal aftershocks of the COVID-19 pandemic, shifts toward more fiscally conservative or right-leaning governments in major donor countries, increasing domestic budget pressures, and a strategic reorientation toward domestic priorities. For recipient countries, the funding environment is further complicated by high domestic debt, misalignment between national health plans and global support, and limited progress in diversifying assistance or mobilising domestic resources, leaving many highly vulnerable to external fluctuations.

Fragmentation, duplication and misaligned priorities

Multiple global actors continue to operate independently at country level, generating high transaction costs, with countries increasingly questioning the value of global level meetings and structures as resources decline. Literature from regional perspectives highlights how parallel procurement channels, overlapping technical assistance missions, and donor-led agendas create inefficiencies and misalignment with national priorities, ultimately undermining coherence and long-term system strengthening. Despite repeated global commitments to improve coordination, including initiatives such as the Lusaka Agenda and sector-wide approaches, implementation remains uneven across the global health landscape.

Country ownership, sovereignty and long-term system strengthening

Many LMICs report having limited influence within the global health system, which is often shaped by donor priorities and short-term funding cycles. This dynamic has led to reactive programming and constrained long-term planning. In response, countries, particularly across Africa and Latin America, are increasingly building health sovereignty and seeking a shift from externally driven vertical programmes towards nationally led long term health system strengthening, centred on primary health care.

What perspectives are emerging?

These challenges point to the need for a more integrated, efficient, and resilient global health system that better serves the most vulnerable. In recent years, debate has intensified over how effectively the current system reaches those in greatest need, with longstanding concerns about governance, fragmentation, and the sustainability of funding becoming more evident. A growing body of literature and policy dialogues highlight that while there is broad agreement on the challenges, there is less consensus on how to deliver responsive, high impact solutions. Below, we highlight the main emerging positions and their implications:

Strengthening governance and accountability mechanisms

Strengthening governance and accountability remains central, with calls for more transparent, participatory decision-making and stronger oversight of global health initiatives to ensure that resources are used effectively and actions align with both global and national priorities. This approach can enhance resource allocation, strengthen trust, and achieve closer alignment between national and global priorities.

Improved coordination and reduced fragmentation

Recent public statements from major donors underscore the inefficiencies and costs that arise when multiple organisations operate independently. At the World Health Summit, leaders such as the Global Fund's Peter Sands and Gavi's Sania Nishtar highlighted the need to streamline the system by improving coordination and consolidating efforts. There is growing support for organisations to collaborate in thematic areas to maximise reach and impact, and ensure more effective use of limited resources.

More equitable representation

Better governance also revolves around more equitable representation of global populations in decision-making and program design. There have been calls for advancing country-led systems, with an emphasis on supporting, not substituting country-level health systems. When country ownership is strengthened, solutions are more responsive to local needs.

Support for regional and local innovation

Investment in regional and local innovation, including local manufacturing and health industry development, is increasingly seen as essential for building resilience. This shift aims to drive self-sufficiency, stimulate local economies, and ensure that health interventions are fit for context and sustainable in the long term.

How is ODA shifting?

Recent Donor Tracker analysis highlights that ODA from the 17 largest DAC donors is projected to fall by US$31.1 billion in 2025, driven largely by cuts from the US. Spain is the only major donor planning to increase its commitments to Gavi and the Global Fund. Most other donors, including the UK, Canada, Germany, France, and Japan, are holding steady or indicating further reductions, a trend driven by persistent budget pressures and a renewed focus on domestic priorities. Norway remains an exception, maintaining its commitment to allocate 1% of GNI to ODA and prioritizing multilateral cooperation.

Our analysis highlights that while emergency response remains crucial, there is a growing call for more predictable, high-quality funding to build resilient health systems and deliver essential services. Donors are increasingly exploring innovative financing mechanisms, such as global taxes on digital services and airline levies, tiered membership fees, and pooled funds, to provide stable resources for global public goods. Health taxes and more investment in local health innovation are also emerging as priorities, reflecting a sector-wide shift toward more diversified and sustainable financing models.

For more information, explore the Donor Tracker innovative financing series to uncover how innovative financing mechanisms can mobilize resources, scale impact, and reshape development systems.

Ongoing reforms and conversations

Follow-up to the Lusaka Agenda is underway, with engagement through GHI governing bodies focused on operationalizing its five strategic shifts:

• Bolstering primary healthcare (PHC) through health systems strengthening;
• Achieving strategic and operational coherence;
• Improved GHI alignment and joint approaches to achieve equity in health outcomes;
• Coordination of approaches to products, research and development, and regional manufacturing to address market and policy challenges; and
• Playing a catalytic role towards sustainable, domestically financed health systems.

Other ongoing conversations include The Accra Reset, led by African partners, which is fostering co-creation between North and South. Spain's Sevilla Platform provides a politically grounded forum for bridging donor and partner priorities. The European Commission is working to align donor positions and technical support for a future-fit system, potentially offering a technical backbone for reform discussions. The HEAR CSO consortium is recognised for its role in ensuring accessibility and inclusion across reform processes. Wellcome's Global Dialogue in 2026 is expected to connect technical, regional, and political priorities, providing a springboard for unified reform efforts.

Across these conversations, a clear core theme remains: placing countries and their priorities at the center of global health reform. As donors recalibrate and new models emerge, the sector is steadily moving toward a more resilient, efficient, and equitable global health ecosystem.

Conclusion

Calls for global health architecture do not exist in a vacuum. Rather, they are linked to broader calls for reform of the international development architecture to better support the world's most vulnerable. Our analysis points to the need for a multifaceted approach to global health, that prioritizes the functions of GHIs. It must also be noted that while this piece has focused on donor-level insights, there are other stakeholder groups, including for example MDBs and private sector actors, that are crucial sources of support and funding to global health, and must be taken into consideration within this multifaceted approach.

This global health series will continue to explore the opportunities and challenges within the space, offering insights on the intersections of health with women's and children's health, AI, and climate to support advocates and organizations navigating this evolving financial landscape.