World Health Assembly: an exclusive new global health order?

The massed ranks of smartly attired decision makers, officials and activists gathered in Geneva, as they have done every year since 1948, to discuss how the world prevents, prepares and responds to health threats. Its importance remains clear. Last year, Dr Tedros Ghebreyesus, Director General at the WHO, announced the adoption of the WHO Pandemic Agreement. Its relevance was recently underscored by the announcement of a “public health emergency of international concern” over the outbreak of Ebola in the DRC and in neighbouring Uganda, which has already led to hundreds of deaths.

However, change is afoot in the wake of dramatically falling levels of global health financing and an erosion of the power base of Geneva, as demonstrated by the growing number of empty offices in the Palais, home to several global health institutions. The centre of gravity of global health is moving decidedly southwards. Ghana’s President John Dramani Mahama was centre stage at the WHA, delivering a clarion call to ‘Rethink Power, Financing and Global Health Delivery’. Mahama is leading the Accra Reset, which aims to rebuild global development cooperation and health sovereignty. It epitomises a shift away from the players who have dominated the Geneva stage over recent decades by centring the leaders of countries who, until now, have been the rule takers rather than the rule makers of the global health system.

The language, the thinking and the instruments are changing fast too. ‘Sovereignty not charity’ and ‘agency not aid’ were phrases used by the advocates from Africa, Asia and Latin America championing the Accra Reset. The role of health insurance for citizens in low- and middle-income countries, the opportunities from AI and the growing levels of domestic investment to finance healthcare were all heralded by the Ministers of Health from Kenya, Indonesia and Brazil, who sit on the High Level Panel that President Mahama has set up to drive the Reset.

global institutions are reforming

Global institutions are being called on to reform, and their leaders are quick to signal their intent to reimagine themselves. Gavi, the Vaccine Alliance, is a case in point: its 2024 review led to the ‘Gavi Leap’, a new country operating model designed to put more resources in countries’ hands and align operationally with the Global Fund. These developments are playing out in front of the stuttering backdrop of the UN80 Initiative, a system-wide structural UN reform aimed to make it more cost-effective, efficient and agile.

All of this is claimed to be catering to the ultimate interests and needs of communities at the sharp end of health systems. President Mahama stressed how under the old order Africa had been regarded as ‘the consumer of solutions created and funded from elsewhere’. This is no longer tenable, and there is going to be no turning back. Every set of stakeholders needs to position itself to reinforce the shift to national sovereignty.

Civil society is no exception to this. It has benefitted from the old order, taking external funds to create parallel systems that have undermined national governments’ efforts to build coherent national health systems and now must seek ways to integrate its capacities into national government-led health systems.

The Assembly closed after adopting a strategy on the economics of health for all, which calls on governments to use tax, trade and other innovative approaches to finance national healthcare delivery. This approach is at the heart of Frontline AIDS’ Transition Initiative, working with national coalitions across five countries in Africa to build sustainable, nationally-owned health systems that include services for marginalised communities, such as sex workers and men who have sex with men.

dangerous rollback on lgbtq+ rights

There is much to be admired in the transformational leadership that President Mahama is showing. However, Mahama continues to signal his support for signing the ‘Human Sexual Rights and Family Rights Bill’ reintroduced by lawmakers in Ghana. The bill imposes up to three years in prison for anyone identifying as LGBTQ+ and, if enacted, would mean organisations advocating for LGBTQ+ people could be prosecuted. LGBTQ+ communities in countries such as Uganda, Burkina Faso, Ivory Coast and Senegal are being heavily persecuted, and Ghana is on the edge of following their example.

It is concerning that a leader driving health systems reform is also potentially working to exclude marginalised populations from those same services. Discriminatory laws drive human rights abuses and make it harder for people to access the health services they need, fuelling the HIV epidemic. The absence of any civil society representatives on the Accra Reset High Level Panel or among the speakers in Geneva is also concerning.

There is a careful balance to be struck here. Civil society should help build sustainable national health systems, navigating its position carefully and demanding a place at the high table based on its decades of experience of responding to the HIV pandemic. But it can’t compromise on its commitments. It must speak out to highlight the risks and limitations of excluding communities and to provide alternative solutions for those who are being sidelined.