The Missing Currency and Ultimate Game Changer in Global Health Architecture Reform Discussion
By Luchuo Engelbert Bain, MD, PhD, FAAS.
Would you board a Boeing aircraft if you did not trust the pilot?
Would you allow a surgeon to operate on you if you knew their patients consistently experienced poor outcomes?
These questions sit at the heart of one of the most important yet under-discussed issues in global health architecture reform: trust.
Global health is currently experiencing a wave of reform discussions. New initiatives, roadmaps, declarations, and commissions are emerging to rethink financing, governance, coordination, and sustainability. Yet many of these conversations focus on structures and institutions while overlooking the currency upon which all successful systems depend: trust.
1. Trust in Competence People trust pilots because they can fly safely. Patients trust surgeons because they consistently deliver good outcomes. Global health institutions must similarly demonstrate competence through measurable results rather than promises.
“Trust is not built on intentions. It is built on performance.”
2. Trust in Accountability Institutions that cannot explain failures, learn from mistakes, or demonstrate accountability eventually lose legitimacy. Reform efforts must clearly define who is responsible, accountable, and answerable for outcomes.
3. Trust in Inclusion Many critiques of current reform efforts highlight who is absent from the room. Communities, implementers, young professionals, researchers from high-burden settings, and frontline practitioners often have limited influence over decisions that affect them most. Trust grows when participation becomes meaningful rather than symbolic.
4. Trust in Fairness Trust declines when power, resources, and agenda-setting remain concentrated in the hands of a few actors. Reform must be seen as fair, transparent, and responsive to the needs of those most affected by global health challenges.
5. Trust in Shared Ownership People support systems they help build. Reform that is done for countries, communities, and partners rather than with them risks reproducing the very problems it seeks to solve.
Some have questioned whether the same elite actors who helped build the current global health architecture are best placed to lead its reform. The answer is both yes and no.
Yes, because we cannot deny that many institutions and initiatives delivered remarkable results. Organizations such as the Global Fund and UNAIDS were established in record time and have saved millions of lives. Those who helped create these systems possess valuable experience and lessons on what worked, what did not, and why. As the saying goes, sometimes to learn something new, one must read an old book.
But the answer is also no. The world has changed. Expectations, needs, power dynamics, and realities have evolved. Reform processes that rely on tokenistic inclusion of younger professionals, communities, implementers, and those most affected by health challenges risk further eroding trust.
Trust must be earned. An excellent surgeon can still fail in a hospital that neglects infection prevention and control.
As it stands, I remain unconvinced. Too many declarations, initiatives, conferences, and reform processes are emerging without clear evidence of how they connect, what success looks like, or how they will be held accountable. National and regional priorities remain where much of our attention should be focused. The burden of proof rests with reform advocates: what concrete evidence should convince us that this time will be different?
Trust cannot be demanded; it must be earned. The institutions that built the current global health architecture have valuable lessons to offer, but past achievements alone cannot guarantee future success. Reform will be judged not by declarations, panels, or new initiatives, but by accountability, measurable outcomes, meaningful inclusion, and demonstrated change. Until reform efforts clearly show why they deserve trust—and how they will deliver differently—skepticism remains not only reasonable, but necessary.
