Cohesion, equity and justice in our health systems can only be achieved by overturning the divisive paradigm of ‘donor countries’ versus ‘recipient countries’ – and bringing all voices to the table is essential for our survival and that of our shared planet
In thinking about global systems, mechanisms, power and equity, I often think of Ursula K Le Guin’s philosophical allegory The Ones Who Walk Away from Omelas, where the prosperity of a utopian city relies on the perpetual suffering of a single child. While most of the city’s people eventually accept this moral tradeoff as necessary for their communal happiness, some are unable to reconcile this reality and walk away. This is a potent metaphor for the relationship between the Global North and the Global South, particularly low- and middle-income countries, left behind and often treated as a mere inconvenience in global affairs. Proposed partnerships for aid and development ring hollow when the necessary far-reaching reforms that could grant LMICS an equal seat at the global table are rarely implemented. Much like the city of Omelas, the world is content to thrive while silently accepting the deplorable inequities and frameworks that keep LMICs in need. Indeed, maintaining the status quo of LMICs keeps the development industry in business.
The Covid-19 pandemic revealed to me – an African humanitarian and advocate for health, education and girls and women’s rights – the stark vulnerabilities of our global and national health systems. Largely resulting from fragmented approaches, political apathy and insufficient collaboration, these burdens pose a risk to all, not just to LMICs. The risk is not just to our health and well-being but also to the global economy and trade. We have both a moral and economic imperative to rectify these issues. To do so, we must critically address politics, power imbalances, institutional effectiveness, gender equality and inclusivity.
We have talked for too long about analysing the problem and developing the solution. Now is the time for action. Through collaborating, empowering the marginalised and fortifying health systems, we can reshape the global health framework to be fairer and more effective. This is not merely an appeal for justice. This pertains to our survival and that of our shared planet.
Global health is often overshadowed by political and power imbalances catering to influential countries, leaving the vulnerable exposed. Mitigating this requires equitable resource allocation, improved global governance and the use of existing commitments such as the Abuja Declaration to guide our actions.
Gender equality and voices from the Global South must be integral to our efforts. This is crucial for sustainable progress and combating fragmentation. Effective coordination among governments, international organisations, civil society and the private sector is key to overcoming fragmentation and ensuring equitable access to health care.
Responses must be tailored to the context and address the social determinants of health. Empowerment of marginalised groups and their representation in decision-making processes are essential for health equity. Community-led initiatives, as in Ethiopia’s and Rwanda’s health transformations, attest to the power of this approach.
Involving diverse sectors to promote transparency, accountability and shared responsibility is vital. Nigeria’s experience with polio reaffirms the need for robust community engagement and cooperative action: through training local volunteers and partnering with traditional and religious leaders, my home country saw a shift from vaccine refusal to effective vaccination campaigns and community trust.
To escape the cycle of panic and neglect surrounding pandemics, we must maintain commitment and invest in our existing health systems. Strengthening infrastructure and fostering a culture of proactive planning is key.
The Intergovernmental Negotiating Body is negotiating a pandemic convention or agreement, signalling a major shift towards health security for all. As the process continues, mechanisms such as the Access to COVID-19 Tools Accelerator ensure there is no gap in pandemic preparedness and response as the world remains vigilant against new and existing infectious disease outbreaks.
Maintaining institutional memory, political will and sustained commitment are vital for lasting changes. Learning from past experiences, investing in capacity building and consistently prioritising health in political dialogues are the path forward. But institutions must fundamentally change so that they are authentically driven by the needs of low- and middle-income countries, which necessarily requires their engagement in governance and decision making. Systemic change is needed today.
Now is a moment to rise united. We must pledge unwavering commitment to our shared mission: the vision of a thriving world devoid of health disparities segregated by geographical boundaries. The urgency is not just in the need but in the action – it is time to transform our institutions and models. Merely discussing change will no longer suffice. We must embody it.
Political leadership must unequivocally confront our shared global challenges, casting aside parochial pursuits. The traditional entrapment of insular interests and institutional rivalries have long hindered our collective well-being. Our topmost goal must remain a world where every individual’s safety is guaranteed, regardless of the threat of future pandemics or global health emergencies.
Grand declarations and ornate meetings are futile if we shy away from the grit and grime of backstage work – from battling to bridge divides to overturning the status quo, work that achieves much more than abstract grandstanding. These endeavours will edge us closer to attaining true equity in the global health architecture and justice universally. The very foundations of the institutions currently leading many interventions must be radically reformed. We must be unafraid to rebuild from the ground up, discarding the debris of outdated structures and ingrained inequities. We must build institutions that mirror the world we now live in and not the world of the 1950s.
Achieving authentic diversity
While we applaud diversity in boardrooms, it is not enough to merely seat a Black or Brown individual at the helm of an institution that has yet to critically examine its own misuse of power and discrimination against individuals from the Global South. True diversity and inclusion cannot be achieved through ‘black or brown washing’ an institution that remains stained by deep-seated inequalities. We must remain vigilant in addressing institutional racism that resists diversity in boardrooms and staffrooms. Authentic diversity must be fostered at the individual and organisational levels through dedicated and committed leadership and role models. Failure to ensure such diversity will continue to contribute to fragmentation. As long as overt racism still exists, we will never achieve collective security and health for all.
The divisive paradigm of ‘donor countries’ versus ‘recipient countries’ must be overturned. We must instead understand that the possession of resources should not be the determinant of the volume of a country’s voice in tackling issues and taking decisions that affect us all. The most vulnerable individuals often dwell in countries that lack wealth, but their stories, their plights, their solutions should not be silenced.
Inspired by those who chose to abandon Omelas, rejecting happiness built on the torment of a single child, we too must be brave enough to shatter the chains of the status quo. We cannot tolerate a world that flourishes on the unjust subjugation of the less fortunate. We must undertake the solitary, challenging journey towards a world where everyone, regardless of colour, wealth or location, has an equal seat at the global table. This is our moral and economic imperative. It is a daunting journey, but a necessary one. Only then can we truly say we are navigating towards an equitable and just global health framework that leaves no one trailing behind.