The current debate about reforming the global health architecture is, at its core, a debate about power — who holds it, who is losing it, and who intends to use this moment of rupture to consolidate it on new terms.

It is remarkable how thoroughly this political reality has been obscured by the procedural vocabulary in which the present architecture debate is conducted: “coherence,” “coordination,” “efficiency,” “fit for purpose.” These are the preferred terms of those who benefit from keeping the structural conditions producing health inequity off the table. These are intellectual property regimes that restrict technology transfer, financial architectures that extract capital from low- and middle-income countries at rates vastly exceeding development assistance, care workforce supply chains organized around the systematic export of trained health workers from countries that cannot afford to lose them and data extraction through tech companies and b-lateral deals. A serious reform agenda would require confronting the political and economic interests of precisely the states that dominate global health governance.

There is no global health architecture

Let’s be clear: there is no global health architecture – but there is an epistemic architecture that must be addressed as a power structure. There is an accumulation of organizations, funds, initiatives, and compacts built over eight decades to shape the agenda and serve specific political interests at specific historical moments — dependent on donors and replenishment rounds and now left to compete and survive when those interests shift. The Joint United Nations Programme on HIV/AIDS (UNAIDS), GAVI, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Global Health Security Agenda, the Pandemic Fund and the list goes on: each was created because existing institutions were judged either too slow, too political, too independent, or insufficiently controllable or because there was a political interest that could be best served by creating yet another global health institution.

The legitimacy of who produces the evidence, who controls surveillance systems, who sets research priorities: these are governance questions, not technical ones. The concentration of evidence production in high-income academic institutions and philanthropically funded research organizations systematically shapes what counts as a global health priority, what gets funded and whose interventions get evaluated. Just think of the constant repeat of the “lives saved” measure. In response, regional bodies and public health institutions in the Global South are now working with determination to define and establish their own health agendas as well as their data sovereignty. They would benefit from a strong independent World Health Organization (WHO) that can address such epistemic power imbalances systematically.

The power of definition

The power of definition matters because it shapes what reforms get proposed. If there is an architecture, it can be optimized; if there is a power structure, it must be contested, especially in a period of rupture. Yet structural dependency stands in the way. The United States has concluded multilateralism no longer serves its strategic interests. It has withdrawn from WHO and is constructing a parallel universe anchored in bilateral conditionality, plurilateral health security compacts, and the quiet redirection of funding toward organizations and instruments it controls directly. The appropriate analytical frame is chokepoint politics: the systematic leveraging of indispensable positions — financing, data flows, supply chains, regulatory standard-setting, pathogen access — to extract compliance and reorder dependencies.

Characteristic of the architecture debate is to have WHO featured as just another international organization in crisis. Many forget, some do not even know, and others do not want to mention that it is one of the very few bodies in the international system with the constitutional authority to negotiate and adopt binding international legal instruments. The International Health Regulations are legally binding on member states. The Framework Convention on Tobacco Control was negotiated under WHO’s constitutional authority. A genuine Pandemic Agreement with enforceable provisions on Pathogen Access and Benefit Sharing (PABS) and mandatory technology transfer obligations could be too. In addition, WHO’s norms and standards — on pharmaceuticals, food, air quality and the like — are the bedrock of health and safety the world over.

The dominant reform narrative does not recognize the structural interests that underfunding WHO serves. At present, the PABS negotiations are the most precise diagnostic instrument for this dynamic, that is why they are so difficult. The question of who owns pathogen sequences, who controls manufacturing capacity, and who captures the resulting economic value has been in negotiation in one form or another for nearly two decades, ever since Indonesia’s December 2006 decision to stop sending influenza virus specimens to WHO’s Global Influenza Surveillance Network (GISN).

WHO’s constitutional uniqueness must be defended, not diluted

Strengthening WHO means strengthening its assessed contribution base even further, thus creating an institution that would be harder to instrumentalize. That is why the recent – albeit still insufficient – increase of assessed contributions was such a breakthrough. It will be the most important legacy of the present Director-General to his successor. A well-resourced, politically independent WHO with genuine enforcement capacity and a broad assessed contribution base would challenge the states and industries that currently profit from the absence of binding global health law. WHO’s constitutional uniqueness must be defended, not diluted. The impulse to “streamline” and “coordinate” the broader ecosystem frequently means reducing WHO to a technical secretariat — stripping it precisely of its unique legal authority.

As Antonio Gramsci predicted, in times of change «a great variety of morbid symptoms appear”.1 The architecture debate lacks a political theory of change adequate to the rupture, but there is perhaps one priority goal that all architecture initiatives should commit to take forward: how to build the material conditions — manufacturing, surveillance, workforce, data sovereignty — that make equity structural and tangible. These are the building blocks of a serious reform agenda. A critical part of this is to create the material conditions for WHO to support this agenda for change by playing a key role in building the foresight and organizational designs to apply when political windows of opportunity open and to use its convening power to support the building of new coalitions to move forward.

The views expressed in this commentary are those of the author and do not necessarily reflect the views of the World Health Summit (WHS). This commentary is part of the WHS Perspectives series on global health architecture. Additional perspectives from other contributors will be published in the coming weeks.