Wellcome CEO joins leaders warning the window for global health reform is closing

Since the Lusaka Agenda was agreed in December 2023, a number of proposals have set out visions for reform of the global health system. While there is broad consensus on the diagnosis, namely that significant change is required, there is far less agreement on how reform should be delivered in practice.

Rethinking the global health system for a new international order, published today in Nature Medicine, takes a different starting point. Rather than revisiting the case for change, it focuses on the more difficult question of what practical, politically feasible reform looks like and how responsibility for delivering it should be shared across the organisations in the system.

The paper is published just eight days before the opening of the UN General Assembly's high-level General Debate in New York on 22 September, as countries and institutions grapple with a rapidly evolving global health environment. 

Over the coming year, several major reform initiatives, including the Accra Reset and a WHO-hosted process on the future of the global health architecture, are expected to report their findings, while wider shifts across the global health landscape continue to shape the context for change. The window in which reform can be shaped is narrowing.

The authors set out seven changes to how the global health ecosystem should work:

• Put country-driven decision-making at the forefront of reform, with national governments setting priorities and global health organisations supporting rather than directing action
• Simplify and streamline the system, creating a clearer division of labour between organisations
• Move from aid dependency to stronger national health systems, with domestic financing becoming the foundation of healthcare while maintaining targeted international support where there is vulnerability
• Integrate disease-specific programmes into broader health systems, shifting away from parallel, donor-funded delivery models towards stronger primary healthcare services
• Focus international cooperation on challenges countries cannot solve alone, including pandemic preparedness, disease surveillance, research and development, and access to medicines and vaccines
• Strengthen regional collaboration and South-South cooperation, enabling countries to work together on shared priorities
• Graduate from debate to implementation, arguing that the need for reform is already widely accepted and that the priority now should be delivering practical, politically achievable change.

John-Arne Røttingen, Chief Executive of Wellcome and one of the paper's co-authors, said the debate now has to shift to focusing on practical routes for delivery.

"For many years, the global health community has produced reports, reviews and commissions. The question now is not whether the system should change, but how and when. We need to move beyond broad aspirations and engage with the practical choices, trade-offs and implementation challenges that meaningful reform will require."

He added that the risk is settling for reforms that change too little: "If we are to do more than tweak the status quo, we cannot afford to exclude potentially transformative options from our discussions. There is a risk we settle for superficial change if we are driven by institutional interests."

“Putting countries in the driving seat will be key. Additionally, by aligning funding and technical support behind country-led plans we can build a simpler, more effective and more accountable global health system.”

The paper's co-authors bring perspectives from multilateral organisations, national governments, health agencies, research institutions and civil society. 

They include: Kumanan Rasanathan, Giulia Loffreda and Amirhossein Takian of the WHO Alliance for Health Policy and Systems Research; Keith Cloete of the Western Cape Department of Health and Wellness; Githinji Gitahi of Amref Health Africa; Octavio Gómez Dantés of Mexico's National Institute of Public Health; Hajime Inoue of the International University of Health and Welfare; Catherine Kyobutungi of the African Population and Health Research Center; Ntobeko A.B. Ntusi of the South African Medical Research Council; Kelechi Ohiri of Nigeria's National Health Insurance Authority; Minghui Ren of Peking University; Diah Saminarsih of the Center for Indonesia's Strategic Development Initiatives; Soumya Swaminathan of the M.S. Swaminathan Research Foundation; and Viroj Tangcharoensathien of Thailand's International Health Policy Program Foundation.

Wellcome believes in the power of science to build a healthier future for everyone. Recognising that science alone does not change lives, Wellcome wants to ensure that the global health ecosystem enables discoveries to translate as effectively as possible into improvements in people's lives around the world. 

As an independent global philanthropy investing in research to address health challenges, Wellcome is uniquely placed to bring together scientific evidence and the perspectives of partners across global health to support practical discussions about reform.

Building on the five regional dialogues hosted by Wellcome in 2025 and the global dialogue convened in Bangkok in Spring 2026, Wellcome will continue to engage with reform processes to identify areas of consensus, surface trade-offs and ensure country and regional perspectives are reflected in global conversations.