Global health shouldn’t rely on charity. Now is the time for reform

In May 1980, the World Health Assembly declared smallpox the first human disease to be eradicated worldwide. Many claim it to be one of the greatest achievements in global health.

Disease-specific initiatives and institutions have proliferated since, achieving great things. Yet expanding opportunities to improve health has not resulted in a sustainable global health system – one able to protect lives against the reality of multiple, intersecting health challenges.

The global health system has become a complex, fragmented network. Individual programmes may be efficient, but the system is not. It relies too heavily on medical tools and technologies at the expense of strengthening primary healthcare. It lacks clear accountability. Market failures persist. Inequity pervades. Most people in the world – 4.5 billion – still lack access to basic health services.

We must see this as an opportunity for change.

War, geopolitical tensions, stagnating economies, public purses squeezed by escalating national defence, health and welfare bills – these are all factors in depleting public and political will to pay for international development.

Abrupt sweeping cuts to US foreign aid are biting hard. The UK, EU countries and others are also reducing development aid for health.

You can’t ignore the deep sense of shock at this week’s World Health Assembly. The hard truth is that this money is not coming back any time soon.

But there is also evidence of leaning in, not pulling away from multilateralism – through the historic signing of the Pandemic Agreement and agreement of a 20% increase in annual membership fees for the World Health Organization.

We must now double down on resilience, and act on long discussed reform.

This is an opportunity to build a better global health system.

Above all, it is time to transfer power in the international health architecture to the countries most affected by health challenges. National governments should be responsible for their populations’ health. Altruism and aid will always have a role. But when international aid is seen as charity, donors make decisions without involving the people who potentially have the most to gain.

Affected countries have played vital roles in research, innovation and health improvements. However, international aid, seen as charity, has too often been delivered without effectively connecting to national priorities.

As chief executive of Wellcome, one of the world’s largest philanthropies to advance science for health, I recognise we have played a role in shaping that system in the past. As well as increasing our global investments in health research, we are committed to support a radical rethinking of the global health architecture for the future.

An important starting point is the recent Lusaka Agenda, the culmination of a 14-month engagement that I co-chaired with Mercy Mwangangi, chief executive of the Social Health Authority in Kenya. It identified key changes needed in global health financing by giving countries a more central role in prioritisation and planning rooted in primary health care, with a joined-up approach from external financing partners.

At this week’s World Health Assembly, thanks to leadership shown by Nigeria’s health minister, Muhammad Pate, member states will vote on a resolution urging increased domestic spending on health and better oversight of health financing. It’s a pivotal decision for member states.

Positive developments can also be seen in several African and Asian countries and there is clearly support for reforms to the global health system in line with the ambitions and directions of the Lusaka agenda. But there are different views on how we take forward change, and who should lead.

In support of country-led efforts at the World Health Assembly, Wellcome this week began to set out plans for five dialogues, each led from a different part of the world, to reimagine a global health ecosystem fit for the future. By the end of 2025, they will come together to build a consensus for action.

We in the global north should listen to and respect calls and commitments from leaders in low- and middle-income settings for greater self-reliance. The global north – government, philanthropy, business – should be partners, not fixers. That means investment aligning with national priorities in recipient countries, with governments implementing by default. International bodies like the World Health Organization will remain vital to strengthen cross-border actions, though they will also need to change, improving supra-national capabilities at both regional and global levels.

This scale of reform will not be easy. But neither was eradicating smallpox, a disease that had persisted for centuries. Science and medicine played their part in solving that challenge, but it took a force of will that transcended Cold War divides; open sharing of technology to enable global manufacture of transformative innovations; extraordinary, simultaneous population-wide vaccination efforts across multiple countries.

Through similar inspiring international collaboration and scientific advances, humanity has improved child survival, maternal health and longevity. We have found ways to prevent and treat HIV, malaria, tuberculosis, Ebola and Covid.

Smallpox is the only disease we have entirely defeated. It doesn’t have to be the last. Most diseases cannot be eradicated, though. To solve the urgent and overlapping health challenges facing the world, we need a different approach.

We need to be brave and honest. The business-as-usual of global health is not working for those who need it most. Let’s go beyond charity and redefine the system so it works for everyone in a changing world.