Wellcome's “Future of Global Health” Initiative: What is the bottom line?
Wellcome has recently published five discussion papers on reimagining the global health "architecture." In advance of the UNGA in New York next week, we have summarized them below.
Background
In this brief, we summarize discussion papers from five different regions[1] reimagining global health architecture commissioned by Wellcome as part of its “Futures in Global Health Initiative.” We also review a recent comment published in Nature Medicine on the functions of the global health system in a new era. We aim to provide a neutral read for busy people - and have avoided editorializing on any of the ideas presented!
Overall Summary
● The Wellcome discussion papers highlight a broad consensus on shifting power away from donor-led systems and moving away from the ad hoc and opportunistic model. Each regional paper brings a distinct framing lens of justice, sovereignty, climate, fragility, or systemic redesign to the global reform debate.
● The papers emphasize innovation and how processes and institutions must change to tackle challenges, as well as coordination across global health actors, and sectors such as climate change and financial inequality.
● In terms of institution building, the Asia-Pacific and Europe and North America papers propose some form of global health coordination body or institution, either as a new organ or by leveraging existing organizations.
● The Nature paper complements this debate by proposing core functions of the global health system and how they should operate across different contexts. It further proposes a set of guiding questions for addressing current challenges to build the global health system in a new era.
Next steps
Wellcome will hold five regional dialogues on global health reform over the coming months. Figure 1 shows dialogue conveners by region.
Figure 1. Convening organization for upcoming regional dialogues as part of Wellcome’s Future of Global Health initiative
[1] Asia and the Pacific, Africa, Europe and North America, Latin America and the Caribbean, and the Middle East and Central Asia.
Annex 1: Individual paper summaries
1. Asia and the Pacific paper
Proposing a Global Commons Coordinating Council and A Set of Six Enablers for the Global Health Architecture by Khor Swee Kheng, CEO, Angsana Health, Malaysia, and Visiting Assistant Professor at the School of Public Health, The University of Hong Kong.
Summary
This paper proposes a Global Commons Coordinating Council (GCCC) as a coordination mechanism between the WHO, UNFCCC, IMF, World Bank, and International Association of Insurance Supervisors (IAIS). It highlights the “Triple Challenge” of health, climate change, and global economic justice, and sets out six enablers.
Key Reform Principles / Proposals
● Global Commons Coordinating Council (GCCC): A coordinating mechanism (i.e. not a new institution) linking WHO, UNFCCC, IMF, World Bank, and IAIS; first step toward a future Global Commons Governance Council.
● Triple Challenge: Health, climate, and economic justice must be addressed together.
● Six Enablers to Strengthen the Architecture:
Separated functions to create checks and balances
Sunset clauses for laws and organizations
National Triple Score (NTS), a composite score, to benchmark performance comprising health, climate and economic justice metrics
Financial incentives using the NTS ranking and rewarding good performance
Compliance mechanisms to verify and enforce commitments
Global Financial Compact to build predictable health financing
● Nation-State Primacy: Countries remain the main actors but should be incentivized into a “race to the top.”
● Pragmatic Reform: No new institutions; focus instead on coordination and creating conditions for others to act.
2. Africa paper
Rethinking the Global Health Architecture in Service of Africa’s Needs by Catherine Kyobutungi, Executive Director, African Population and Health Research Center, Kenya, and Co-Director of the Consortium for Advanced Research Training in Africa.
Summary
This paper calls for a radical transformation of the Global Health Architecture (GHA) to serve Africa’s needs, moving away from saviorism and power imbalances rooted in colonial legacies. It envisions re-imagined African health systems that prioritize primary healthcare (PHC) as the organizing framework for health systems strengthening (HSS), supported by sovereign national institutions, knowledge-based learning systems, and locally driven accountability. The reformed GHA should be catalytic, complementary, time-bound, flexible, and rooted in equity, dignity, and solidarity.
Key reform principles and proposals
● Shift from Saviorism to Sovereignty: Center African leadership in priority setting, capacity building, and implementation, with HIC actors playing a supportive rather than directive role.
● Primary Healthcare as Foundation: HSS efforts should focus on PHC, providing cost-effective, equitable, and locally adaptable health systems.
● Catalytic Role for Global Actors: International organizations and GHIs should catalyze system change, not substitute for national institutions.
● Knowledge and Evidence Systems: Build robust African-led data ecosystems, knowledge translation mechanisms, and policy units to ensure evidence-based decision making.
● New Scientific and Training Models: Reform global health curricula, reward systems, and narratives to dismantle colonial legacies, elevate African expertise, and integrate indigenous knowledge.
● Financing Reform: Repurpose existing GHIs into a consolidated mechanism that funds HSS, coupled with increased domestic investment and innovative financing approaches.
● Equity, Dignity, and Solidarity: Reform must explicitly address historical injustices and create a just system centered on African agency and mutual respect.
3. Europe and North America paper
A Proposal for Transforming the Global Health Architecture by Kelly Lee, Tier 1 Canada Research Chair, Global Health Governance and Professor of Global Public Health, Faculty of Health Sciences, Simon Fraser University, Canada.
Summary
This paper argues that global health has never had a true “architecture” but rather a fragmented, donor-driven patchwork that is now in crisis following U.S. withdrawal and declining trust in institutions. Instead of tinkering with existing organizations, it calls for a fundamental redesign using “good building practices” and innovation thinking. The proposal envisions a Global Health Nexus (GHN) as a connected, agile, network-based system with streamlined governance, core functions, and sustainable financing to replace today’s ad hoc system.
Key reform principles and proposals
● Global Health Nexus (GHN): Consolidates and rationalizes WHO and major GHIs into a network coordinated by a new Global Health Organization (GHO).
○ GHO structured with a Constituents Assembly (states and non-state actors), Executive Board (hub leads), Scientific Board (independent experts), and a Stewards Council (strategic oversight).
○ Six hubs responsible for core functions: stewardship and security, technical cooperation, knowledge and data, financing, public engagement, and compliance and accountability.
● Core Functions Approach: Limit scope to global public goods that cannot be provided by countries acting alone, such as standard setting, surveillance, pooled financing, and risk management.
● Innovation Agenda: Replace fragmented donor-led arrangements with a planned network by reallocating existing capacities into functional hubs, introducing more inclusive governance, and strengthening evidence-based, transparent decision-making.
● Financing Reform: Replace discretionary donor contributions with tiered membership fees and global taxation (digital services tax, airline levies, or small shares of national taxes). Seek cost savings through decentralized hubs located in lower-cost regions.
● Pathway to Change: A 24-month roadmap that includes a Global Declaration on rebuilding health architecture, a Founders Circle for transitional funding, public consultations, a Stewards Council to design the GHN, technical and legal drafting, and a Global Health Summit to adopt founding documents.
4. Latin America and the Caribbean (LAC) paper
Rebalancing the Scales: A New Architecture for Global Health Justice by Paola Abril Campos River, Research Professor and Director, Evidence and Action for Health Equity School of Government and Public Transformation, Institute for Obesity Research at Tecnológico de Monterrey, Mexico.
Summary
This paper argues that global health reform must be rooted in health justice, shifting power from donor-led institutions to regional leadership and fairer financial systems. It calls for a distributed architecture where WHO focuses on global norms and emergency coordination while technical and policy tasks move to regional bodies. Financing should transition from aid to investment and the author proposes four regional reforms: restructuring PAHO, creating a new regional public health center (CRESALC), launching a Health Justice Knowledge Atlas, and establishing a Health Justice Fund.
Key reform principles and proposals
● Health Justice Paradigm: Confront exclusion, redistribute power, and address structural and commercial determinants of health, climate, and equity.
● Rebalance WHO: Retain core functions (stewardship, norms, emergency coordination) but devolve research, technical support, and policy to regional actors.
● Regional Empowerment: Strengthen PAHO as a strategic coordinator, establish CRESALC as a broader public health institution, and promote South–South cooperation.
● Knowledge and Accountability: Create the Health Justice Knowledge Atlas as a transparent data and decision-making tool.
● Fair Financing: Shift from aid to long-term investment through regional funds, sin taxes, and reduced reliance on external donors.
● Participatory Governance: Regional funds and institutions to be governed by multistakeholder boards with representation from civil society, Indigenous groups, and smaller countries.
● Practical Regional Steps: Four proposals tailored for LAC: redesign PAHO, create CRESALC, build the Knowledge Atlas, and establish the Health Justice Fund.
5. Middle East and Central Asia (MECA) paper
Designing a New Global Health Architecture for the Middle East and Central Asia Region by Shadi Saleh, Founding Director, Global Health Institute and Professor of Health Systems and Financing, American University of Beirut, Lebanon.
Summary
This paper highlights the heterogeneity of the region, with some countries stable and wealthy while others face conflict, fragility, and heavy refugee burdens. It outlines seven key functions for a reimagined global health architecture: sustainable financing, inclusive governance, equitable health outcomes, focus on refugees and marginalized groups, stronger national and subnational health systems, provision of public goods such as surveillance and vaccines, and crisis preparedness. The proposed architecture is regionally anchored but globally engaged, with reforms centered on solidarity-based financing, coordination, innovation, and institutional strengthening.
Key reform principles and proposals
● Core Functions: Finance sustainability, inclusive governance, equitable health outcomes, attention to refugees and displaced groups, stronger health systems, provision of regional/global public goods, and improved crisis preparedness.
● Regional Anchoring: More health institutions and initiatives based in MECA, modeled on Africa CDC, with funding from regional collectives (League of Arab States, Gulf Cooperation Council, Organization of Islamic Cooperation).
● Financing Reform: Establish a MECA Health Solidarity Fund with pooled resources, value-based financing, rapid-response mechanisms, and private sector engagement.
● Coordination: Create formal mechanisms and secretariats to streamline global and regional health financing, reduce duplication, and improve efficiency.
● Innovation and Manufacturing: Invest in regional R&D hubs, manufacturing capacity, and AI/digital health tools to reduce dependence on external supply chains.
● Institutional Strengthening: Shift from fragmented, disease-specific programs toward whole-system investments in PHC, public health, and data systems.
● Reform Pathways: Five practical routes including efficiency reviews, solidarity-based financing, shifting power to regional and national actors, data-driven allocation of funds, and digital health reform.
Annex 2: Nature Medicine Comment
Function of the global health system in a new era by Kumanan Rasanathan, Executive Director of the Alliance for Health Policy and Systems Research, WHO, Geneva; Keith Cloete: Head of Department at Western Cape Department of Health, South Africa; Githinji Gitahi: Global Chief Executive Officer, Amref Health Africa, Nairobi, Kenya; Octavio Gómez-Dantés, Senior Researcher at the Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico; Diah Saminarsih: Founder and CEO, CISDI, Jakarta, Indonesia; Soumya Swaminathan: Chair person, M.S. Swaminathan Research Foundation, Chennai, India; Amirhossein Takian: Professor and Founding Director, Center of Excellence for Global Health, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; John-Arne Røttingen: CEO, Wellcome Trust, London, UK.
In a new era of reduced aid and shifting geopolitics, the authors argue that reform of the global health system must start with clarity on global health functions, country contexts, and operating models.
Key questions
Drawing from three dominating pressures that are currently shaping global health - demand for national ownership, adaptation to funding cuts, and call for reforming the overall global health architecture - the authors propose a set of guiding questions (Figure 2) help to set a vision for a new global health era.
Figure 1. Dimensions and guiding questions for reforming the future of global health architecture.
The functions and contexts of the global health system
To unpack the global health system, the authors identify a set of functions that global health institutions deploy with varying degrees of country ownership and collaboration in different contexts (Figure 3). They see that (1) Substitution in delivery (where external actors fund and oversee execution of health systems) should be rare, temporary, and limited to humanitarian crises, fragility, or marginalized groups; (2) Financing support should complement domestic resources, help countries transition to self-reliance, and focus on humanitarian and low income settings; (3) Technical assistance should be delivered through national and local institutions and South-South exchange; and (4) Global public goods like surveillance, R&D, and standard setting should meet the demands of countries.
Figure 1. Functions and contexts for global health
Other considerations
The authors identify several issues that require consideration in a new global health era. These include:
● Regionalism: Increasing emphasis on regional institutions requires clarity on roles vis-à-vis global-level actors, which have gained criticism on their impact.
● Financing: Countries need to expand domestic revenues, but debt and fiscal constraints are major barriers. Options like solidarity taxes or debt relief are noted, though politically difficult.
● Transition: Moving away from external financing and vertical programs is necessary but requires careful design.
● Equity: Within-country inequities and the needs of marginalized populations must be central to reform.
● Multisectoral action: Health depends on broader determinants, requiring collaboration beyond the health sector.
Conclusion
The authors conclude that (a) Sovereignty and self-reliance will define the next phase of global health (b) Countries want to define their needs rather than accept donor prescriptions (c) The future global system should support transitions away from substitution and aid dependency, and ensure equity and solidarity even in constrained financial conditions.