The Alliance Lift is a series that spotlights the journeys of Alliance alumni shaping health systems around the globe. In this Q&A, we meet Dr John-Arne Røttingen – a Norwegian physician, health researcher and global health leader whose career bridges science, policy and delivery.
John-Arne is Chief Executive Officer of the Wellcome Trust and previously served as Norway’s Global Health Ambassador and as head of the Research Council of Norway. A long-time friend of the Alliance – and Chair of our Board from 2011 to 2015 – he has helped steer vaccine trials during the Ebola outbreak, played a key role in founding the Coalition for Epidemic Preparedness Innovations, or CEPI, and championed integrating research, policy and practice.
We asked John-Arne about the ideas and experiences that shaped his approach to health policy and systems research, what it will take to safeguard gains amid shrinking aid and shifting geopolitics, and how the global health system can better deliver for countries – from investing in research capacity to prioritizing global public goods and equity.
Learning from the past
Q: People may know about your extensive experience in infectious diseases and research – like steering vaccine trials for Ebola in the wake of the 2014 West Africa outbreak. But can you tell us about your journey with health policy and systems research? What sparked your interest in this field?
I started studying medicine with a strong interest in molecular biology, in understanding the causes of disease and how the body works. But I was also politically engaged. In the early 1990s I co-founded a study group called Patient Earth with other students and professors, combining global health and planetary health.
Those combined interests stayed with me. After my PhD, I pivoted to infectious disease epidemiology and global health, where I saw the interface between biology, epidemiology and policy-making.
When I returned to Norway after my studies, I remember a conversation with a State Secretary in the Ministry of Foreign Affairs. I asked, provocatively: why are you not using more of the research base and academic expertise in Norway, given all the millions being spent on global health? That challenge led to me being invited to the Alliance Board in the early 2000s.
Q: You have been involved with the Alliance for nearly 20 years. In 2011 you became Chair of the Board. What were some of the highlights for you and the contributions you felt the Alliance made during your tenure?
A few highlights come to mind. During that period we doubled down on research synthesis and systematic reviews – synthesizing both locally relevant and global evidence as a foundation for policy.
We advanced work on systems thinking, recognizing that policy-making is not linear. Understanding the complexity of health systems and the different levers, or control knobs, was key.
We also developed ideas around integrating learning into health systems, what we called learning health systems. These are systems with built-in capacity to evaluate performance, learn from successes and failures, and improve continuously. This work combined implementation science, operational research, and health policy and systems research.
Q: You are now CEO of the Wellcome Trust, which is often perceived as more of a biomedical funder, though it has also supported the Alliance. How do you see the role of health policy and systems research in Wellcome’s work?
It’s true that most of Wellcome’s funding has been in biomedical research, and we will continue to support that. But Wellcome has also been a strong funder of humanities and social sciences relevant to health.
Alongside discovery research relevant for life, health and well-being, we now focus on three challenge areas: infectious diseases, mental health, and climate and health. Across all three, new technologies alone are not enough. They need to be implemented at scale, delivered through systems, and benefit many. That is Wellcome’s vision: to improve health for everyone.
To achieve that, evidence-based policies and system strengthening are essential. Health policy and systems research is the applied approach that allows us to bridge science, society, and implementation.
Living in the present
Q: Today it feels like global health is in a very different era compared to even a few years ago. Would you agree?
Absolutely. For two decades we lived through what many call the golden age of global health. Resources were abundant, and successes were measurable, particularly around the Millennium Development Goals.
The pandemic also showed what is possible. We developed new vaccines in record time. But access was unequal, proving that while science succeeded, our global health system did not.
Now we face economic pressures, conflict and declining aid budgets. The challenge is that aid delivered outcomes but did not always build lasting health care capacity in countries. We now need to focus on health sovereignty – strengthening primary health care, local systems and self-reliance.
Q: Aid flows are shrinking sharply. Analyses suggest global health financing could fall back to 2009 levels, and resources available within countries back to 2018 levels, with consequences for programmes and services. What does this mean for global health?
We don’t know the full impact yet, but the consequences are already being felt around the world. HIV treatment programmes are being disrupted, malaria efforts are losing support, health workers are no longer being paid and are looking for other work. Modelling suggests that USAID cuts alone could lead to 14 million additional deaths by 2030.
At the same time, there is political will in some countries to take on more health care delivery responsibilities. Nigeria’s health and finance ministers, for example, want to take over the HIV programme at 40% of its current cost. That ambition is commendable. But transitions must be phased – they cannot be done in six months; they need at least five years.
Q: One area that has received less attention is the impact on research systems themselves, especially in low- and middle-income countries. What are your reflections?
Every country needs research capacity to improve health systems and outcomes. For decades, much of this has been funded by external aid. Now, as part of the self-reliance agenda, governments must invest in higher education institutions, national research centres and system capabilities.
This is not only about policy and systems research. Countries also need biomedical research to support local pharmaceutical production and health technology manufacturing. After the pandemic, many governments are eager to build such capacities.
Levelling up for the future
Q: The Alliance teamed up with you and other co-authors to write a comment in Nature Medicine on the functions of the global health system in this new era. What are the main messages?
The paper poses big questions – and they are essentially health policy and systems research questions. We asked: what core functions must the global health system deliver in the future?
First, with fewer resources, aid must be concentrated on countries with the greatest need. Second, in fragile and humanitarian settings, external support will still be required.
Third, we must prioritize global public goods – research and development, new technologies, setting norms and guidance, systematic reviews and global surveillance systems.
Finally, we must prepare for cross-border health threats. Epidemics and pandemics require collective action globally. The system is only as strong as its weakest link.
Q: Reform is urgently needed but difficult to achieve. What is Wellcome doing to help move this debate forward?
We believe a functioning global health system is essential for science to have impact and for everyone to benefit from its advances. That is why we commissioned five regional analyses and are facilitating dialogues – led by actors in those regions – to shape reform proposals.
We are building on the Lusaka Agenda, which called for “one country, one plan, one budget.” The pandemic showed the power of coordination. Now we must seize the opportunity to embed reform, amplifying country voices and ensuring stronger governance.
Q: What about research itself? Will Wellcome continue to support research across country income groups, and how do you see the balance between global and national responsibility?
Research is a global endeavour. We fund in high-, middle-, and some low-income countries. For instance, in Malawi we support a major research centre in Blantyre that is world-class and works closely with government.
Our aim is that research funding not only generates knowledge but also strengthens capacity locally and sustainably. That means working with governments and local institutions so that investments today build the health research systems of tomorrow.
Q: Are you optimistic about the future? Can the global health system adapt?
I am an optimist, a glass half full guy. These are difficult times, but opportunities are greater than ever. If we align resources, talent, and focus where the needs are greatest, we can make enormous progress.
4.5 billion people lack access to essential primary care. That is unacceptable. This shows where we need to be focusing efforts if we are to improve health globally.
Q: Finally, what message would you share with those working in health policy and systems research today?
Stay committed. Stay optimistic. And focus on working with your local colleagues and counterparts, sharing your insights and research, to improve health through evidence informed solutions and policies.
