Reforming the Global Health Architecture: Important Conversation, Wrong Starting Point? A critique
By Luchuo Engelbert Bain, MD, PhD, FAAS.
“The global health architecture reform discourse will gain credibility not when it speaks most loudly about changing hypothetical global systems, but when it humbly recognizes and supports countries in building resilient systems capable of protecting their own people first.”
The rise of bilateralism and increasingly radical forms of nationalism poses a significant challenge to global health cooperation. COVID-19 exposed the uncomfortable reality that much of what was described as global health solidarity often remained stronger in textbooks than in practice. While the world demonstrated extraordinary scientific performance through the record-time development of COVID-19 vaccines, the simultaneous experience of vaccine hoarding, unequal access, and protection of national interests revealed that solidarity carries multiple meanings in global health. The pandemic taught a difficult lesson: in moments of crisis, national priorities frequently override collective global commitments.
These realities make discussions on reforming the global health architecture important. Many of the weaknesses currently highlighted in global reform debates have been known for decades and were simply exposed differently during COVID-19 and the ongoing reductions in oversees international development assistance.
From the Wellcome Trust-funded regional convenings to the Accra Reset discussions, momentum is growing around reforming the global health architecture. Conversations on governance, financing, equity, and institutional power have become increasingly prominent in global health spaces.
- Old Problems Presented as New Discoveries
Questions surrounding the effectiveness, legitimacy, and financing of the World Health Organization and the broader global health ecosystem have existed for years. Fragmented financing, donor dependency, weak accountability, and unequal power relations have long been documented. The current reform movement therefore risks presenting long-standing concerns as newly discovered crises. Better late than never — but humility and historical honesty are necessary.
- National Health Systems Remain the Real Priority
Perhaps the most important concern is that reform conversations may distract attention from more urgent domestic priorities. The primary challenge facing many countries is not the absence of a reformed global architecture, but weak national health systems. Countries must ask difficult questions about governance, workforce development, domestic financing, accountability, surveillance capacity, and service delivery. Sustainable progress will come less from abstract global restructuring and more from functioning national systems capable of responding to local realities.
- Regional Cooperation Matters More Than Distant Architecture
The reform debate becomes far more meaningful when grounded in regional cooperation. It is reasonable to ask whether Burkina Faso gains more from surveillance cooperation with Belgium than from closer collaboration with Niger and Benin. Regional manufacturing, pooled procurement, epidemiological intelligence, workforce mobility, and cross-border preparedness are likely to deliver more practical impact than endless reform panels.
- Reform Is Not Equally Urgent Everywhere
Another revealing reality is that the urgency around global health architecture reform is disproportionately concentrated in Africa and other low- and middle-income countries. Many high-income countries do not frame this issue as a pressing national concern and often do not host WHO country offices. This does not invalidate reform efforts, but it does suggest that the issue is experienced differently across contexts and should not automatically be framed as a universally shared global emergency. The emergency is at country, and at most, regional level.
- Inclusivity and Power Remain Unresolved
Much of the conversation is still led by a relatively small, and elite, network of global health institutions, experts, and funders. Communities, frontline implementers, ministries, and local systems thinkers remain underrepresented or are included only tokenistically. This weakens legitimacy and risks reproducing the same power asymmetries the reform movement seeks to address.
For low- and middle-income countries especially, appreciating the limitations, political – diplomatic realities (national interests first), and deficiencies of the global health system — while strengthening domestic financing, governance, surveillance, workforce capacity, and regional cooperation — is becoming increasingly critical for sustainable health security and long-term resilience.
Global health architecture reform is important, but it should remain secondary to the more urgent work of strengthening national and regional health systems. Rwanda’s response to Marburg outbreaks demonstrated the power of strong surveillance systems, national leadership, and regional coordination. In an increasingly polarized world marked by weakened multilateralism and growing radical nationalism, countries may need to accept a difficult but important reality: sustainable health security begins at home.
No country considered developed today primarily attributes its progress or national achievements to external global support. The same applies to health systems. Sustainable advancement has largely emerged from strong national agendas, long-term political commitment, domestic investment, effective governance, and leadership willing to take responsibility for building resilient institutions and systems. Global partnerships can complement national efforts, including in health, but they rarely substitute for visionary leadership, strategic planning, domestic financing, and sustained internal commitment to national development and health priorities.
The discussion on reforming the global health architecture is important, but its credibility depends on honestly prioritizing the real elephant in the room: building stronger national health systems, improving governance, and unlocking sustainable domestic financing and regional resilience first.
