Global health transformation 3x3x3
Global health is undergoing a period of profound and irreversible transformation. Many of the proposals for improvement, innovation and change that are now debated at length should have been tackled head on 10 years ago. But organisations rarely move out of gridlock without a crisis.
Three crises for global health
Since 2020, global health has been hit by three consecutive crises. First, the Covid-19 pandemic exposed long-standing structural limitations and inequities in global health. Second, the United States abruptly withdrew financial and political support from global health efforts in early 2025, so the decades-long system of hegemony and financing of global health could no longer be maintained. And third, we have the hard reality of a major geopolitical powershift, along with growing deadly conflicts. The world is in a multipolar moment. Countries are testing and reshuffling alliances and dependencies as well as priorities and ideologies. One thing is clear: the Global South – a politically applied term for very different actors and interests – wants to define the future. Recent statements by the G20, the BRICS and the Shanghai Cooperation Organization make this very clear.
Three systemic issues must be addressed
These global health challenges will not be resolved by better managerial solutions like incremental, ‘more for less’ changes. Every crisis leaves a trail of destruction – real deaths of real people, most of them in the poorest countries. A Lancet HIV report suggests that anticipated international aid reductions may lead to 10.8 million additional new HIV infections by 2030 and 2.9 million HIV-related deaths in children and adults by 2030. And it also brings the death of institutions and organisations as well as accepted norms, rules and goals. A wide range of organisations in the global health ecosystem – which got very cosy, despite the funding competition – are affected.
Even the United Nations has said the Sustainable Development Goals are “disappearing in the rear-view mirror, as is the hope and rights of current and future generations” – the death of the SDGs.
Stopping the destruction requires addressing three key systemic issues – and understanding they cannot be solved overnight and are not for the faint of heart. First is the challenge of weakened global solidarity amid shrinking trust, reflected most prominently in the response to past and prospective pandemics but also in the hegemonic systems established for global development finance, leading to the death of development aid. The multipolar world is less controllable, and the agenda is being changed by the Global South, from money to the power of definition. This will play out in the negotiations on the Pathogen Access and Benefit Sharing System, still to be negotiated for the Pandemic Agreement to take the next step in acceptance and ratification.
The second big challenge is the lack of intersectoral and systemic action to address the consequences of the climate–health interface, in relation to resurging vector-borne diseases and their global spread and also to non-communicable diseases. Perhaps global health should be redefined as planetary health. Moving from silos to systems is essential.
This, of course, is hampered by the third challenge: the institutional fragility of international health organisations, starting with the World Health Organization, which is confronting a 20% cut in funding for 2026–2027. The WHO is at the core of the global health ecosystem and critical for coordinating health action at the international level. It is where the negotiations of how the three crisis and the three challenges intersect – and what systemic responses should be found in a difficult geopolitical climate.
Three areas for strategic reform of the WHO
Amid this uncertainty, the legitimacy and leadership capacity of the WHO – and its future role as a central actor in the global health ecosystem – are at stake. There are deep concerns about its capacity to lead effectively when multilateralism is out of favour and new challenges loom. With two colleagues, I have recently suggested three areas of reforms. They will require significant political will by member states, a commodity in short supply.
Refocus the WHO on its core mandate. The WHO cannot be everything to everyone. Its future lies in concentrating on its constitutional mission. Its core functions are norm and standard setting based on sound science amidst escalating misinformation and disinformation, health intelligence and surveillance, pandemic preparedness and emergency coordination, and convening power. It must remain the forum for global health diplomacy and international dialogue on global health priorities. It must set bold new future-oriented health agendas, many – such as planetary health – based on a new systemic approach. The new way of working in health must be made manifest by a key organisational paradigm shift, as happened in 1978 when the Alma-Ata Declaration on primary health care was adopted.
Ensure the WHO’s financial independence. A shift to a funding model anchored in fully unearmarked assessed contributions is overdue. By 2030, 80% of the WHO’s budget should come from assessed contributions, reflecting each country’s economic capacity. That proposed target will become realistic and acceptable through focusing on the four core functions proposed above. Such a reform must be co-led by countries of the Global South, not only by traditional donor states. It is a political opportunity to reshape the WHO’s governance and agenda more equitably and representatively. It is especially the middle powers that should make use of this opportunity. China will emerge as the largest contributor if the US leaves, but next to the classic donor countries on the list of the first 20 contributors of assessed contributions, Brazil, India, Mexico, Korea, Saudi Arabia and Russia will be critical to move such reforms forward.
Strengthen WHO governance and accountability. WHO governance must align with the expectations of member states and the international community. The World Health Assembly must regain its authority as the primary global forum on health, as the world needs a platform for health policies across geopolitical divisions. But the Executive Board must also be revitalised and reformed. The WHA must initiate discussions on post-2030 global health priorities in the next two years, especially in the face of the death of the SDGs.
Building a new system based on the 3x3x3 dynamics
We need to study the interface of the three crises with the three systemic challenges to be able to propose systemic and sustainable solutions that can be taken forward by a reformed and strengthened WHO. One thing is clear – it will need long-term as well as substantial commitments – it will need the interface with geopolitical powershifts and the emergence of new leaders in global health and development.
