A new comment in Nature Medicine led by the Alliance reflects on how the global health system can adapt in a time of shrinking aid, shifting geopolitics and rising calls for sovereignty and self-reliance. The piece asks important questions about the functions of the global health system, what should be delivered in different contexts and at different levels, and how the system should operate into the 2030s and beyond.
Less than two years after the Lusaka Agenda called for reform of global health initiatives, the landscape has shifted dramatically. The article identifies three types of conversations that are shaping the future of the global health system:
- Country leadership and sovereignty – frustration with how development partners operate and growing demands for local ownership.
- Financing in crisis – how to mitigate the impact of severe cuts in development assistance and reduced domestic fiscal space for health.
- Reforming the global health architecture – what a more effective, efficient and equitable system could look like.
To frame these discussions, especially the latter, the authors set out five modes for how the global health system functions (and considers the contexts where each is most appropriate in this new era):
- Substitution – where external actors step in to deliver services directly.
- Financing support – external funding for health systems and programmes within countries.
- Technical assistance – direct technical support by external actors for policy development, programme design, and service implementation within countries.
- Development of global public goods for countries – research and development, data and evidence syntheses, norms and standards, and other shared resources that countries can adapt and apply.
- Supporting transnational global public goods – collective action for challenges such as pandemics, climate change, or harmful commodities that cannot be solved by any one country alone.
The comment poses a range of questions on the global health system’s scope, operating model and financing, as well on how to achieve equity and manage the transition towards greater self-reliance. The authors call for country actors to answer these questions and demand what they require from the global health system, rather than accepting global prescriptions.
Lead author of the piece, Executive Director of the Alliance for Health Policy and Systems Research, Kumanan Rasanathan, notes: “The overarching question we are asking in this new era is how might the global health system strategically differentiate what it delivers for varying contexts – including the operating model to do so - and how might this be financed?”
John-Arne Røttingen, Chief Executive Officer of the Wellcome Trust, and co-author of the piece, adds: “We probably need to continue some level of external mechanisms for delivering health care in the most fragile and humanitarian contexts. But the global health system must put greater focus on providing global public goods that benefit all countries.”