Funding cuts over the past year or so have created a crisis for multilateral health institutions. Spotlight editor Marcus Low argues that which institutions will emerge from this crisis, and in what form, with real consequences for the health of people in South Africa.

In recent weeks, there has been a deluge of articles from global health experts concerned about how multilateral health institutions should and should not be redesigned. These include articles by UNITAID Executive Director Philip Dunton, GAVI CEO Sania Nishtar and co-authors, former WHO Acting Director-General Anders Nordstrom, former New Zealand Prime Minister Helen Clark and Peter Piot, the driving force behind UNAIDS from the mid-90s to 2008.

The immediate cause of all this debate is the harsh reality that funding for multilateral health institutions has been cut dramatically in the past year, primarily, but not exclusively, due to the United States' withdrawal from such international forums in favor of bilateral agreements. Even before the funding cuts, the financial outlook for organizations like the World Health Organization (WHO) and UNAIDS was bleak. During the last year, it has been completely mired in crisis.

WHO has already undertaken extensive organizational restructuring. Last year, a UN document raised the possibility of UNAIDS being “eliminated” by the end of 2026. It is likely that we will see many more organizations shrink or disappear altogether in the coming years.

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Why does it matter?

The multilateral health institutions we have had in recent decades are not perfect. They were often highly politicized, fraught with power imbalances, and not always able to respond quickly and effectively to health emergencies.

But still, it is clearly true that when it comes to health care, multilateralism has yielded many tangible benefits that are helping people survive. In a world where each country stands alone, these advantages would easily be lost.

There are many examples of such benefits. WHO's treatment guidelines for diseases like HIV and TB are public goods that are invaluable in many countries – here in South Africa they were particularly important as an antidote to the crackpot science that flourished in a period of state-sponsored AIDS denialism. Sharing genomics data between countries was of utmost importance at the height of the COVID-19 pandemic. Over an even longer period, sharing data on influenza strains has enabled the rational selection of vaccine components for each hemisphere each year. Drug regulators in different countries are increasingly sharing some of their work to speed up their processes and avoid duplication.

This year, a new HIV prevention injection containing the antiretroviral lencapavir is being launched in South Africa and several other countries, largely with the help of the Global Fund, another international entity. Thanks to the market-shaping work done by UNITAID, the Gates Foundation, the Clinton Health Access Initiative and Wits RHI, a steady supply of low-cost lencapavir should be available in about a year or two from now. Such market-shaping often involves committing ahead of time to purchasing a certain quantity of a product to encourage manufacturers to invest in production capacity, thereby accelerating the market for the product.

Then there's the recent history of how quickly a new antiretroviral drug called dolutegravir was introduced into South Africa since 2019 – with more than five million people taking it here today. The Geneva-based Medicines Patent Pool (MPP) negotiated the license, allowing generic competition to begin years earlier than it otherwise would have. This enabled lower prices and supply security, helping the widespread use of dolutegravir here and in dozens of other countries.

It is clearly in South Africa's interest to help keep mechanisms such as the above running.

But reducing the value of these institutions to something purely technical would miss the essence of what drives them in the first place. The reality is that multilateral health institutions have often been at their most effective when people were driven by the need to address urgent health needs, for example in the early days of UNAIDS. The belief that people's health matters, no matter who they are, or where they live – essentially a belief in human rights – can make the difference between an ineffective bureaucracy and a vital health movement. Our current crisis is not only one of technical capability, but also one where the animating power of human rights-based thinking is being challenged.

So how should we think about redesigning global health?

There are some tensions between fighting to maintain what we currently have and adopting major reforms. For example, on the one hand, given last year's aid cuts, people have good reason to be concerned about the possible closure of UNAIDS as a harbinger of further unraveling of the global HIV response. On the other hand, there are legitimate questions about whether UNAIDS is still fit for purpose, given how the HIV epidemic has changed over the past three decades.

The most useful contribution to how to think about all this comes from Nordstrom and his co-authors. They outline four key paradigm shifts that help bring the present moment into focus. Their paper is worth reading in full for the specifics, but here's a brief description of the four paradigm shifts:

The first shift is about recognizing the ongoing fundamental changes in the global burden of disease and demography. In short, while the major threats in the past three decades were the infectious diseases malaria, tuberculosis and HIV, they are increasingly being overtaken by non-communicable diseases (such as diabetes and hypertension) and mental health disorders. This change has not yet been reflected in the architecture of multilateral health institutions.

The second change relates to the recent transfer of power from Geneva in Switzerland and New York and Washington in the United States to countries and regions, giving rise to an increasingly multipolar world. “This shift does not mean that multilateral cooperation is obsolete,” the authors write, “however, it does require a clarification of which tasks should be performed at the global level in the future, and which should be performed by national and regional bodies.”

The third shift refers to the increasing pressure to modernize the landscape of global health institutions. The authors write: “Leaders of low-income and middle-income countries have repeatedly criticized the lack of systemic support, the inefficiencies of vertical initiatives, and the resource-intensive bureaucratic processes that come with them”. Keeping these external and internal pressures in mind, he argues that there is a need to move from a complex and competitive system to a simple, need-based and agile system.

The fourth change is linked to countries' increasing commitments to increase domestic financing for health, as well as the decreasing relative importance of development assistance. Although some international support will remain necessary for low-income countries and humanitarian responses, the authors argue that domestic resources must be the engine of a new ecosystem and ways of working together.

All of these changes are now taking place in a broader geopolitical context that Canadian Prime Minister Mark Carney recently described as a “breakdown in the world order.” He asserted that the great powers have turned their back on the rules-based world order and have begun to use “economic integration as weapons, tariffs as leverage, financial infrastructure as coercion, supply chains as vulnerabilities to be exploited”. This shift can already be seen in the US's pivot from multilateralism to bilateral health agreements.

As Carney put it: “The very architecture of the multilateral institutions that the middle powers have relied on – the WTO, the UN, the COP – is under threat.”

He argues that middle-powers like Canada, and I would argue South Africa, should aspire to be part of this group, charting a way forward where they are not overly dependent on superpowers like the US and China. Avoiding such over-reliance is certainly an obvious lesson to take from the US's sudden cuts in health aid last year.

Maybe the first harsh reality to emerge then is that the rift that is occurring in global geopolitics is also occurring in the world of global health. To think that we can go back to the situation WHO or UNAIDS was in twenty years ago is wishful thinking. The “rupture” may take time to spread, but it will spread all the way.

What then is to be done?

Carney also said that the rules-based order was actually not working as well for everyone as we liked to pretend. To some extent, something similar can be said for multilateralism in health. Getting the job done was often difficult, the politics were often complicated, and when it came to a crisis, over something like patents on drugs, the US and Europe almost always had the upper hand.

As noted above, countries like South Africa benefited from multilateral forums in very concrete ways, but those benefits were never widely appreciated. Ultimately, it is telling that many national governments have failed to commit the funding needed for WHO to do its job – even before the current US withdrawal.

Perhaps then, for the restructuring of multilateral health institutions to succeed, governments will have to reevaluate and appreciate anew why it is that we need multilateral health institutions in the first place.

This will require a thorough and honest assessment of what we have achieved from these institutions in recent decades. Things like market shaping, patent pooling, pooled purchasing, sharing of genomics and other data, regulatory harmonisation, guideline development, research collaboration and multilateral fund raising have been and will continue to be important. We must ensure that whatever emerges over the next few years, we have multilateral mechanisms that can work across all these areas.