Challenges for global health at the Johannesburg Summit – facing the paradigmatic shift

Over the last two and a half decades the G20 has contributed to a system of mediated stability in international relations and the recent presidencies have given a strong voice to the agendas of the Global South countries. Now we see an emerging shift to a system of open rivalry and increased fragmentation that could well be reinforced through the US G20 presidency in 2026. Can the G20 withstand such a push from soft to hard power, which indicates the end of the global interdependence agenda, the rules-based order and development cooperation. John Mearsheimer terms this approach to international relations ‘offensive realism’. It brings significant challenges for global health as it reshapes a global health development agenda based on equity and cooperation to one based on sovereignty and competitiveness. 

The hollowing out of international organisations and the United Nations currently under way makes it ever more difficult to achieve a broad consensus on matters of global concern such as climate or health. The Sustainable Development Goals, international development commitments and concern for the global commons are increasingly replaced by industrial policy, techno-nationalism and hard power deterrence. In such a context, the logic of global governance must be revisited. The G20 has a great responsibility to address the most pertinent issues in the relations between states on matters of global health and beyond: the lack of commitment to a rules-based system and the erosion of trust.

Fragmenting health governance in a fractured global order

The fractured multipolar system increases the number of flexible coalitions – minilateral, issue-based or regional. This reinforces the complexity and lack of transparency in the already opaque global health system. For example, as the World Health Organization is being weakened politically and financially – reinforced by the declared exit of the United States – other forums take on the health debate such as the G20 health track, BRICS health ministers, ASEAN+3 Health Cooperation, European Union Global Health Strategy and the Africa Centres for Disease Control and Prevention’s networks. 

Multistakeholder initiatives apply network diplomacy to issue agendas such as the Lusaka Agenda on the Future of Global Health Initiatives. These flexible coalitions and initiatives can put health on the political agenda, unlock new financial flows (such as the Pandemic Fund) and drive innovation – but they also risk fragmenting standards, increasing competition and opening the door to forum shopping rather than facing tough negotiations in the governing bodies of the WHO that include all countries. 

Most importantly, by setting parallel health agendas, the many stakeholders have weakened rather than strengthened the WHO, whose constitution states it was set up “to act as the directing and coordinating authority on international health work”. Global health agendas are now divided between commitments to equity versus innovation and increasing concerns about sovereignty versus approaches to address the global commons. The ongoing negations on the Pathogens Access and Benefit Sharing annex to the Pandemic Agreement adopted in May 2025 at the World Health Assembly exemplify this. 

Health information integrity is the new battleground between transparency and control. Control over health information – such as genomic databases, surveillance data and digital public goods – is now an issue of geopolitical advantage when it should be one of global governance. Health data, artificial intelligence and algorithmic models have become national security assets – and also a source of economic benefit and profits, as we see in the increasingly close links between tech industries and government strategies, especially in the US and China. 

Rebuilding trust in a new era

As member states of the WHO turn to other venues to suit their needs, it becomes difficult for the WHO to address the new geo-economic tools that drive a parallel global health agenda in non-health venues: supply chains, critical minerals, sanctions, security and data. Divergent values over privacy, surveillance, human rights, and competing digital and AI architectures are additionally fragmenting consensus. The PABS negotiations illustrate how important it is to equip health diplomats with the required techno-literacy to understand health data, AI and biotech implications. What is urgently needed is a system of trust, interoperability and ethical use in a multipolar digital health world. 

Offensive realism maintains that because in the international system no one can be trusted, seeking maximum power aggressively is rational; health is thus used as a strategic instrument. The G20 and G7 health tracks in contrast have recognised that interdependence makes cooperation rational. The question now is whether the G20 musters the energy and support for a move to rebuild epistemic trust in a fractured world – not as a parallel health agenda and system but as a group of strong WHO member states committed to a WHO that can fulfil its role to act as the directing and coordinating authority on international health work under rapidly changing circumstances. The last G20 in the sequence of Global South presidencies must create the baseline to build a global health system that is committed to equity and grounded in science, whose evidence is legitimate and whose ethics guide technology.