This week I happened to be staying in Geneva on the site where the founders of the Red Cross Movement had met in a smoke-filled room in 1863.
162 years on, the city is now home to 30,000 people working in international organisations and NGOs, all of which was seeded by that one meeting. Alas, for many of those working in the many global health initiatives and other organisations (including the International Commission of the Red Cross that Agulhas are reviewing for MOPAN), the tsunami that began with the US abdication from global collective action is bringing wave after wave of dismissals to the shores of Lake Geneva.
Agencies like UNAIDS, WHO, The Global Fund, StopTB and Gavi are already laying people off, reviewing and cancelling programmes, shrinking both their footprint and their ambition.[i] As budgets shrivel, organisations are looking cautiously at each other, all competitors for potential resources. The implicit contract between donor nations, international institutions, and recipient countries—that well-resourced multilateral agencies would steward global health goods on behalf of all—is fraying. One view is that a more transactional, cost-sensitive, competitive and fragmented order is emerging. Collective action for global goods, multilateralism as we have known it, is on the way out.
Looking away from the global health institutions, we can see how the UN Secretary General has responded to the earthquake of 2025 by repurposing the UN80 reform process to drive structural consolidation of the UN’s organisations. Mandates are being reviewed, duplications identified, functions dispensed with. Even before this review is completed, posts, departments and agencies are already being relocated from high-cost hubs to cheaper cities. The old order is being restructured.
As yet no such formal process exists for the global health initiatives.
But something does appear to be beginning.
There is no equivalent of the UN Secretary General for the health system. The process that might lead to the reshaping of global health institutions is more organic. In contrast to the Secretary-General’s mandate-focused rationalisation, a more needs-based approach to health system reform might be emerging. And this could, eventually, result in more radical change. A dialogue (as yet out of sight in closed, if not smoke-filled, rooms) among key donors who maintain a commitment to multilateralism is underway. The European Union is helping animate a discussion with a group of donors including the French and British. This dialogue may lead to the reshaping of the Global Health Institutions.
At the core of the dialogue is the question of resources. But before that we must identify what those resources are for: what are the fundamental global health needs that require multilateral support? Once that is established, we can turn to the question of resourcing: what financing will it take to address those global needs and how can we, collectively, provide it?
Taking this needs-based (if not zero based) approach as the starting point may be slower than the UNSG process. But it might lead to a radical restructuring of roles and a more fit-for-purpose global architecture. Particularly if countries, and specifically African countries (whose health systems have been most hit by the withdrawal of funds), are included in the discussion. It would take some brave decisions, since it will inevitably lead to the consideration of mandates and a painful discussion of who is best placed to do what – including who should no longer be doing certain tasks.
The Fourth International Conference on Financing for Development in Seville, starting on 30 June, is where these discussions might come out into the open. While the conference is part of the legacy of the Paris Aid Effectiveness process, it is now seen as the place where the urgent challenges facing global funding, and especially global health funding, might be addressed. I will be watching and hoping that this will be the case.
Purposeful conversations can make things happen. When Henri Dunant, Louis Appia, Gustave Moynier and the others met in 1863 they had been inspired by the horrors of suffering in war. They saw a need, said something must be done, and did it. Together. Now more than ever, we need effective conversations that lead to a new architecture for collective responses to global health needs.
[i] https://www.devex.com/news/exclusive-unaids-will-lose-more-than-50-of-staff-in-restructuring-110000;
https://www.devex.com/news/who-grapples-with-deepening-funding-shortfall-109783;
https://www.devex.com/news/devex-checkup-trump-admin-proposes-sweeping-cuts-to-global-health-110226