By guest contributor Kate Harvey
Introduction
Access to the highest attainable standard of health is a fundamental human right, and is inalienable from those of life, liberty, and security. In the last half century, we have no doubt made astonishing progress towards better health, demonstrating no shortage in our capacity to innovate. However, the distribution of this progress has been alarmingly unequal. We live in a world that is more interconnected than ever before, yet somehow, we consistently fail to deliver lifesaving care to those who need it most.
Even before the beginning of the second Trump administration, progress towards better health in recent years had stagnated. Now, as life-saving health programs around the world are being gutted before our eyes, it goes without saying that a new model of global health governance is long overdue. In recent months, I have been reflecting on two questions. First: what went so wrong? And, second: where do we go from here?
The Equity Imperative
The colonial origins of medicine are responsible for the imbalance in power in global health today. This can be seen in the ongoing resource theft from Global South countries, systematic exclusion of Global South members from institutional leadership positions, and exploitation of political and economic influence by the North to maintain dominance over countries in the South.
The recent pandemic, for example, illustrated the ways in which this power asymmetry between Global North and South reinforces existing inequities. This was seen in the failure to implement a widespread patent waiver for COVID-19 vaccines, as well as numerous deals made by high-income countries to bypass COVAX, effectively stealing vaccines from low-income countries. Later, these same countries began hoarding vaccines, despite having more than enough for their citizens and numerous calls from experts to share—in Canada alone, an estimated 32 million vaccine doses sat unused and ultimately expired, when they could have instead been donated to save countless lives.
The Global North’s response to the COVID-19 pandemic proves beyond a doubt that as long as this power imbalance persists, so too will inequities in health outcomes. The findings of a 2022 report highlight the extent of this stronghold—less than 3% of board members across 146 global health organizations are from low-income countries. Meanwhile, 75% of positions are held by members of the North, despite this group making up just 15% of the global population. A conscious effort is needed to redistribute power and diversify representation in the leadership of institutions that have been historically dominated by the North.
Accountability for All
A lack of accountability has also left global health in a dire state. Funding for global health programs has traditionally been achieved through official development assistance (ODA), or grants from high-income countries that support health programs overseas. Given that ODA represents a substantial proportion of total health spending in low-income countries, having access to sustained and predictable funding sources is essential. ODA remains largely reactive, however, with contributions increasing in response to crises, but inevitably receding shortly thereafter. In addition, this outdated aid model perpetuates a neocolonial agenda, requiring Global South countries to be completely dependent on bilateral partnerships with the North, which puts them in a vulnerable position.
Furthermore, the contributions to global health programs through traditional means are insufficient for building resilient health systems. In 2023, only five countries met the agreed-upon allocation of 0.7% of gross national income for health-related aid. Despite projected increases in health spending globally, there is still an estimated shortfall of $20-54 billion annually, relative to the level of global spending needed to make progress towards the United Nations health-related Sustainable Development Goals by 2030 (this was the case long before the US backed out of the World Health Organization and dismantled USAID, among other attacks on global health).
In the discussion of accountability, we should also be questioning the role of private companies in deciding who gets access to lifesaving medicines. Pharmaceutical giants exploit intellectual property laws, allowing them to monopolize markets and inflate prices. The result is that many lifesaving drugs and therapeutics are inaccessible to the people who actually need them. This is particularly egregious considering that the public sector provides a substantial amount of funding for drug research and development.
Global Public Investment
It is clear that the current structure of global health governance is unfit for purpose, perpetuating inequities and lacking accountability for Global North actors. Global Public Investment (GPI) is a funding model in which all countries contribute to and benefit from a shared pool of resources. GPI would offer several advantages over the current system, including:
1. Promoting equity in the leadership of global health
By distributing the decision-making power and providing all contributing members a seat at the table, GPI can help to address current exclusionary practices in which a minority of countries decide where the majority of resources are directed. This approach presents an opportunity for genuine collaboration and strengthening of both North-South and South-South ties. A unified mechanism will contribute to a sense of ownership over the global health system as a whole, ensuring that all countries have a stake in seeing it succeed.
2. Ensuring accountability in global health financing
The current system in which funding contributions are decided on a voluntary basis has left the global health system critically underfunded. GPI would improve accountability by requiring all countries to pay their fair share, taking into account national income and wealth levels, as well as the future costs of inaction. Including these future costs in the calculation is essential as it underscores the urgency of the situation, and demands a careful consideration of the consequences of failing to act. Importantly, this approach acknowledges the inherently global nature of health, and that the benefits of investment extend beyond borders.
3. Treating knowledge as a public good, allowing everyone to benefit from its production
To facilitate access to high-quality healthcare globally, we need to reframe health and its production as public goods. This requires a recognition that the privatization of publicly funded research is antithetical to the shared interests of humankind. The market incentives that drive the current research landscape would be removed, ensuring that issues are prioritized according to need, rather than ability to pay. The funds pooled through GPI would be allocated for essential health functions such as research and capacity building, targeting equity as service coverage is expanded.
The promise of a global public investment framework offers a path for reshaping the trajectory of global health. If there is one thing that the past few months have shown us, it’s that progress is far from inevitable. Our ability to address the present threats to global health rests upon our commitment to sustained collaboration. Now more than ever, we must prioritize investing in stronger health systems for everyone, or risk forfeiting the hard-won gains we have made. Amid the precarity of this moment, I know one thing for certain: moving forward, there will be no concept of individual success—only collective failure.
About the author:
Kate Harvey is a first-year master’s student in epidemiology at McGill, with a background in biomedical engineering from the University of Waterloo. She is interested in studying infectious diseases in a global health context, and evaluating interventions to reduce the burden of tuberculosis among underrepresented groups. Kate’s work is guided by a passion for health equity and improving access to care for communities globally.
LinkedIn: https://www.linkedin.com/in/kate-harvey/
Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.