Opinion: Global health can't run on charity — now is the time for reform

As it faces a funding precipice that charity cannot fill, global health needs to double down and act bravely on long-discussed reform. That global health is in crisis is hardly news. At last week’s World Health Assembly, the deep sense of shock after recent, abrupt cuts to development aid was impossible to ignore. There was also a sense of growing acceptance of the hard truth that money lost is not coming back anytime soon. Still, there was evidence of leaning in, not pulling away from multilateralism — through the historic signing of the Pandemic Agreement and agreement of a 20% increase in annual membership fees for the World Health Organization. There were also positive signs of support for reforms to the global health system in line with the ambitions and directions of the Lusaka Agenda — which lays out five key shifts to stimulate change in global health financing over the long term — with the priorities of low- and middle-income country governments front and center. But what’s missing is consensus on how we take forward change, and who should lead in defining the necessary global reforms. That needs to change. “Altruism and aid will always have a role. But when international aid is seen as charity, donors make decisions without involving the people who potentially have the most to gain.” --— An overhaul of the global health system has long been overdue. Disease-specific initiatives and institutions have proliferated since 2000 and have delivered important health impacts. Yet expansion of opportunities to improve health has not resulted in a sustainable global health system — one able to protect lives against the reality of multiple, intersecting health challenges. The global health system has become a complex, fragmented network. Individual programs may be efficient, but the system as a whole is not. It relies too heavily on medical tools and technologies at the expense of strengthening primary health care. It lacks clear accountability. Market failures persist. Inequity pervades. Most people in the world — 4.5 billion — still lack access to basic health services. War, geopolitical tensions, stagnating economies, public purses squeezed by escalating national defense, health, and welfare bills are all now factors in depleting public and political will to pay for international development. It’s not an option to simply try to plug the gaps until we can turn the clock back to what we had before. We must take this opportunity to build a better global health system. Above all, it is time to transfer power in the international health architecture to the countries most affected by health challenges. National governments should be responsible for their populations’ health. Altruism and aid will always have a role. But when international aid is seen as charity, donors make decisions without involving the people who potentially have the most to gain. Although affected countries have played vital roles in research, innovation, and health improvements, aid has too often been delivered without effectively connecting to national priorities. As CEO of Wellcome, one of the world’s largest philanthropies to advance science for health, I recognize we have played a role in shaping that system in the past. Now, as well as increasing our global investments in health research, we are committed to supporting a radical rethinking of the global health architecture for the future. An important starting point is the recent Lusaka Agenda, the culmination of a 14-month engagement that I co-chaired with Mercy Mwangangi, chief executive officer of the Social Health Authority in Kenya. It identified crucial changes needed in global health financing by giving countries a more central role in prioritization and planning rooted in primary health care, with a joined-up approach from external financing partners. Positive developments can be seen in several African and Asian countries from this. At last week’s World Health Assembly, thanks to leadership shown by Nigeria’s health minister, Muhammad Pate, member states supported a resolution to increase domestic spending on health and get better oversight of health financing. It’s a pivotal decision for member states. In support of country-led efforts at the World Health Assembly, Wellcome has set out plans for five dialogues, each led from a different part of the world, to reimagine a global health ecosystem fit for the future. By the end of 2025, they will come together to build a consensus for action. We in the global north should listen to and respect calls and commitments from leaders in low- and middle-income settings for greater self-reliance. The global north — government, philanthropy, business — should be partners, not fixers. That means investment aligning with national priorities in recipient countries, with governments implementing by default. International bodies such as WHO will remain vital to strengthen cross-border actions, though they will also need to change, improving supra-national capabilities at both regional and global levels. This scale of reform will not be easy. To solve the urgent and overlapping health challenges facing the world, we need a different approach. Wellcome hopes that the five regional discussions will foster new ideas that strengthen country responsibilities and accountability, as well as propose how the existing institutional landscape should evolve to better support country priorities and protect against cross-border health threats. We need to be brave and honest. The business-as-usual of global health is not working for those who need it most. Let’s go beyond charity and define a new global health order.