Funding cuts over the past year have created a crisis for multilateral health institutions. Which institutions emerge from this crisis, and in what form, will have real consequences for the health of people in countries like South Africa.

In recent weeks, there has been a glut of articles from global health big-hitters, all concerned with how multilateral health institutions should, or should not be redesigned.

These include articles from Philippe Duneton, Executive Director of UNITAID, Sania Nishtar, CEO of GAVI, and one co-authored by, among others, Anders Nordström, a former acting Director-General of the WHO, Helen Clark, a former New Zealand Prime Minister, and Peter Piot, the driving force behind UNAIDS from the mid-90s to 2008.

The immediate cause of all this debate is the stark reality that funding for multilateral health institutions have been cut dramatically in the last year, mainly, but not exclusively, due to the United States’ retreat from such international forums in favour of bilateral agreements. Even before the funding cuts, the financial outlook at entities like the World Health Organization (WHO) and UNAIDS was bleak. Over the last year, it has tipped over into outright crisis.

The WHO has already undertaken drastic organisational restructuring. Last year, a UN document raised the possibility of “sunsetting” UNAIDS by the end of 2026. It is likely that we will see several more organisations shrinking or disappearing altogether in the coming years.

Why does this matter?

The multilateral health institutions we’ve had in recent decades have not been perfect. They were often overly politicised, fraught with power imbalances, and not always capable of responding quickly and effectively to health emergencies.

But even so, it is unequivocally true that when it comes to healthcare, multilateralism has yielded many tangible benefits that are helping keep people alive. In a world where every country stands alone, these benefits will simply fall away.

There are many examples of such benefits. The WHO’s treatment guidelines for diseases like HIV and TB are public goods that are invaluable in many countries. In South Africa, they were particularly important as an antidote to the crackpot science that flourished in the period of state-sponsored AIDS denialism. 

The sharing of genomics data between countries was critically important at the height of the COVID-19 pandemic. Over an even longer period, the sharing of data on influenza strains has enabled the rational selection of vaccine components for each hemisphere each year.

Medicine regulators in different countries increasingly share some of their work in order to speed up their processes and avoid duplication.

This year, a new HIV prevention injection containing the ARV lenacapavir is being rolled out in South Africa and several other countries, largely with the help of the Global Fund, another international entity. 

A stable supply of low-cost lenacapavir should be available in around a year or two from now, due to market-shaping work done by UNITAID, the Gates Foundation, the Clinton Health Access Initiative, and Wits RHI.

Such market-shaping often involves committing ahead of time to purchase certain volumes of a product to incentivise manufacturers to invest in production capacity, thus kick-starting the market for the product.

Then there is the recent history of how rapidly a new antiretroviral medicine called dolutegravir was rolled out in South Africa from 2019. Today over five million people here are taking it.

The Geneva-based Medicines Patent Pool (MPP) negotiated licenses that allowed generic competition to start years earlier than would otherwise have been the case. That enabled the low prices and supply security that has facilitated the massive uptake of dolutegravir here and in dozens of other countries.

It is clearly in the interest of countries like South Africa to help keep mechanisms like these going.

But to reduce the value of these institutions to purely the technical would miss the essence of what animates 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, as in the early days of UNAIDS, for example.

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 ineffectual bureaucracy and a vital health movement.

Our current crisis is not only one of technical capacity, but also one where the animating power of human rights-based thinking is being challenged.

How should we think about redesigning global health?

There are some tensions between fighting to keep what we currently have and embracing big reforms. For example, on the one hand, given the aid cuts of the last year, people have good reason to be concerned about the potential closure of UNAIDS being a precursor to the further unravelling of the global HIV response.

On the other hand, there are legitimate questions as to whether UNAIDS is still fit for purpose, given how the HIV epidemic has changed over the last three decades.

One of the most useful contributions on how to think about all this comes from Nordström and his co-authors. They outline four key paradigm shifts that help bring the current moment into focus. Their paper is worth reading in full for the nuances, but here is a brief paraphrasing of the four paradigm shifts:

•   The first shift is about recognising the fundamental changes underway in the global burden of disease and in demography. In short, while the key threats in the last three decades were the infectious diseases malaria, tuberculosis, and HIV, they are increasingly being overtaken by non-communicable diseases (like diabetes and hypertension) and mental health disorders. This shift is not yet reflected in the architecture of multilateral health institutions.
•   The second shift relates to the recentring of power from Geneva in Switzerland and New York and Washington in the USA to countries and regions, giving rise to an increasingly multipolar world. “This shift does not imply that multilateral cooperation is obsolete,” write the authors, “however, it requires a clarification of which future functions should be performed at the global level, and which should be performed by national and regional bodies.”
•   The third shift refers to the growing push to modernise global health institutions. The authors write: “Leaders from low-income and middle-income countries have repeatedly critiqued the dearth of systemic support, the inefficiencies of vertical initiatives, and the resource-intensive bureaucratic processes that accompany them”. Considering these external and internal pressures, they argue that there is a need to move from a complex and competitive system to a simpler, needs-based, and agile system.
•   The fourth shift is linked to the declining relative importance of development assistance, coupled with countries’ rising commitments to increase domestic financing for health. Although some international support will remain essential 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 shifts are now occurring within the broader geopolitical context of what Canadian Prime Minister Mark Carney recently described as a “rupture in the world order”.

He stressed that the great powers have turned their backs on the rules-based world order and have “begun using 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 multilateral institutions on which the middle powers have relied – the WTO, the UN, the COP – the very architecture of collective problem solving, are under threat.”

He argues that middle-powers like Canada, and I’d argue South Africa too, should aspire to be part of this group, and chart a way forward where they are not overly reliant on super-powers like the US and China. Avoiding such an over-reliance is of course also an obvious lesson to take from the US’s abrupt cuts to health aid last year.

Maybe a first harsh reality to come to terms with, then is that the rupture that is taking place in global geopolitics is also occurring in the world of global health.

To think that we can go back to the way the WHO or UNAIDS were 20 years ago is wishful thinking. The “rupture” might take time to propagate, but it will extend all the way.

What is to be done?

Carney also makes the point that the rules-based order wasn’t in fact working as well for everyone as we liked to pretend. To a lesser extent, something similar could be said for multilateralism in health.

Getting things done was often hard, the politics was often tricky, and when it came to the crunch, say on something like patents on medicines, the US and Europe almost always held sway.

As outlined above, countries like South Africa benefited in very concrete ways from multi-lateral forums, but somehow those benefits were never widely appreciated. Ultimately, it is telling that so many national governments have failed to put up the money the WHO requires to do its work – even before the current US withdrawal.

Maybe then, to make a reset of multilateral health institutions a success, will require that governments reassess and newly appreciate 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 gained from these institutions in recent decades. Things like market-shaping, patent pooling, pooled procurement, sharing of genomics and other data, regulatory harmonisation, guideline development, research cooperation, and multilateral fund-raising have all been important and will continue to be so.

We must make sure that, whatever emerges in the next few years, we have multilateral mechanisms that can deliver in all these areas.

But we will have to accept that those entities might look quite different from what we’ve come to know in recent decades. There will certainly be areas in which we still need global institutions like the WHO, but for some issues, we might get more done by working with coalitions of the willing, or collaborating at a regional level – as we’re already seeing with the African Medicines Agency (although South Africa rather inexplicably hasn’t yet ratified the related treaty).

The reality is that apart from governments not being willing to spend more on health at the moment, the enabling geopolitical substructure that we’ve been relying on for decades has given way.

In many respects, this has been a disaster for our common good, but it is also an opportunity to craft new and more fit-for-purpose multilateral health institutions that are animated by a shared commitment to human rights. This is an opportunity that countries like South Africa must grasp.

As Carney put it: “We know the old order is not coming back. We shouldn’t mourn it. Nostalgia is not a strategy, but we believe that from the fracture, we can build something bigger, better, stronger, more just. This is the task of the middle powers, the countries that have the most to lose from a world of fortresses and most to gain from genuine cooperation.”

*Low is editor of Spotlight. This article was co-published with Spotlight,  a South African public health magazine that aims to deepen public understanding of important health issues. The article mentions The Gates Foundation, which provides some funding to Spotlight, but is editorially independent.

Image Credits: US Mission in Geneva / Eric Bridiers via Flickr, USAID Press Office, Gilead, MPP.