As the task force working on the WHO-led reform process prepares its interim report by November, we ask global health experts: Can this process deliver a more equitable global health system? 

Our three-part interview series with Dr Amitabha Sarkar (Tampere University, United Nations Research Institute for Social Development (UNRISD)), Dian Maria Blandina (United Nations University) and Aggrey Aluso (Resilience Action Network Africa (RANA)), explores what meaningful reform would look like, whose voices are shaping the debate and whether countries and communities with less influence will gain greater control over the decisions that affect their health.

Dian Maria Blandina is an Indonesian primary care physician, health policy researcher and Policy Research Associate at the United Nations University - International Institute for Global Health (IIGH). Her work focuses on the political economy of health, global health governance and the structural factors shaping health systems and health equity.

She holds a medical degree from the University of Indonesia and has pursued global public health studies at Queen Mary University of London and graduate research at Aristotle University of Thessaloniki. Her work bridges academic policy research with grassroots perspectives through her engagement with civil society organisations including the People’s Health Movement and the Geneva Global Health Hub.

Looking at the process so far, what gives you the most reason for optimism and what concerns you most?

Dian: I am not sure if I can call it optimism, but I am quite excited that this process has opened the debate again about global health governance and everything that is wrong with it, including structural barriers in global health governance. These issues were often discussed informally among civil society actors and in closed-door roundtables, but were rarely articulated openly and explicitly.

Another point I find encouraging is that, even in the official WHO documents, it is explicitly acknowledged that there are serious issues, including fragmentation, duplication, weak governance, a lack of country ownership, power imbalances, and financing issues. 

Another thing I find encouraging is that, last May, many Global South countries stood up and insisted that the process remain member-state-led. They also pushed for a mechanism to ensure that this actually happens, rather than leaving the process to be driven and shaped primarily by the most powerful donors. I will explain this concern:

When reading the documents themselves, it is confusing that in the preamble, all of the mentioned challenges are recognised, but then it is not really spelled out how WHO or the Task Force would be able to address it. The document recognises the fragmentation, but then later on in the text, fragmentation is described as a technical issue: too many actors, insufficient coordination. There is no acknowledgement that this fragmentation was politically produced. These parallel mechanisms, multi-stakeholder initiatives are platforms that have been created by powerful donors, like philanthropists, who exercise greater influence in shaping agendas that serve their interest. It is confusing when those very same actors become the principal architects in shaping this reform. So this is why we all need to ask - and member states did ask during WHA79 - what this reform is for, where this reform is going and whether it can genuinely challenge the power relations that underpin the current global health governance system.

I think what is particularly disappointing for many people is the gap between the rhetoric of inclusivity and the reality of the process. Academia, civil society and regional institutions should have meaningful opportunities to participate and that should go beyond being consulted or having their views heard.

What would meaningful change look like from your perspective, and how realistic is it that the process will deliver it?

Dian: That is a challenging question, but I know for sure, meaningful change cannot start with just mapping institutions and then discussing how to coordinate between these powerful actors better and just aligning existing funding streams. We need to broaden the debate considerably and look more critically at what underpins these financing mechanisms, how they emerge, and whose interests they ultimately serve.

If we are serious about strengthening country ownership, we need to revisit the question of what it actually takes for countries to shape and lead their own health initiatives. That means addressing the constraints on their fiscal space and discussing how to expand it. 

Another issue I do not see adequately addressed in the WHO document is what it actually means to put WHO at the centre of global health governance. Its authority has been significantly weakened, and even the discussions that led to this reform process did not originate within WHO itself.

WHO is the only multilateral institution with a mandate to advance global public health as a whole. Strengthening its authority is therefore essential, particularly when it comes to coordinating the many different actors involved in global health. It means that health comes first and money and politics come second. 

Because exactly this has always been the problem in the global health governance. If we can strengthen WHO, it will trickle down to our countries and strengthen public health systems, and our Ministry of Health’s political and financial capacity. During WHA79, Member States were concerned about what this process would ultimately mean for WHO, and whether it might change the organisation's role.

Because an organisation's functions can change even if its formal mandate remains the same. Over the years, global health initiatives have taken on many functions that WHO should be leading, from emergency preparedness to supporting countries in building their manufacturing and vaccine production capacities.

Yet, over the past decade, WHO has often been little more than an observer in these initiatives. It can provide technical input, but it is not the primary decision-maker. I think clarifying WHO's mandate is partly about addressing this imbalance and reinforcing WHO's leadership in global health governance.

Could you explain more what you mean by widening the fiscal space of countries? What concrete proposals are being discussed, and what would you propose?

Dian: Not only the framing of the term fragmentation, but also of the term “financing” has been diluted in the final official document on the reform process. Financing is framed in the context of declining official development assistance, with the emphasis on how we can coordinate better and use less money more efficiently.

But there is no real acknowledgement of the structural constraints behind this funding crisis, particularly the limited fiscal space countries face and the burden of debt. Nor is there any attempt to connect this discussion with parallel UN processes, such as the UN tax convention, which could be highly relevant to addressing these challenges. 

Which actors do you expect to have the greatest influence on the reform discussions?

Dian: I think it is quite clear that G7 countries are likely to benefit the most from this process. The agenda is already being shaped in ways that reflect and support G7 priorities, like they have been described in the G7 political declaration on the topic from April 2026.

Germany's role as co-chair of the Task Force, alongside the participation of G7 countries across its various workstreams, reinforces this. I think we can be reasonably confident that G7 priorities in global health will be safeguarded throughout the process. I am not necessarily saying that is a bad thing in itself, but it is important to recognise how this political dynamic works. G7 countries also have prominent voices in other global health initiatives and international health institutions, which are Task Force members. And then there are the major philanthropic foundations, which are predominantly based in the Global North and wield considerable influence in global health. These actors and institutions can reinforce one another.

The real question is what the rest of us can do to make sure our interests are also represented. Ultimately, that is politics: everyone has their own interests, and those who can coordinate, collaborate and build alliances most effectively and quickly are more likely to secure them. I am afraid countries in the Global South have not yet reached that level of coordination.

To what extent do you think low- and middle-income countries will be able to shape the reform agenda?

Dian: I am not sure how much we can still shape the process at this stage. The tight timeline puts Global South countries at a significant disadvantage, as they do not have the staff capacities to follow the process.

But I think they can still try to act collectively and articulate a clear set of demands that they can push for throughout the process. The scope is now largely limited to improving coordination, rather than fundamentally restructuring global health governance or addressing its underlying structural barriers. But even within these constraints, there are still concrete steps that could be taken to strengthen the position of Global South countries and advance their interests.

There are quite a few countries willing to defend not just Member State ownership in principle, but what that ownership should actually mean in practice: stronger health systems, more predictable financing that supports long-term domestic development, and meaningful technology transfer.

There is also an opportunity to connect this process with parallel negotiations, particularly the PABS negotiations. By linking these different processes, countries could develop a more coherent and coordinated position. For example, access and benefit-sharing should not be confined to the pandemic preparedness mechanism; it should be embedded more broadly in the global health governance system itself.

What are likely to be the main political fault lines or contested issues in the process?

Dian: I think one of the key fault lines relates to what I said earlier about the very tight timeline. The process seems to favour a model of governance that is lean, flexible and concentrated in a relatively small circle of actors. The idea is that a small group can define the agenda and develop proposals first, which are then presented to everyone else for approval. Of course, this is efficient and makes it possible to move quickly. But it is not necessarily democratic, nor does it guarantee that everyone's needs and voices will be heard.

An alternative model, would prioritise a more inclusive and universal form of multilateralism. I think Global South countries could insist on that. And, in my view, they could even decide collectively that the current agenda does not serve their purposes and risks undermining the very principles of multilateralism. Yet, for some reason, Global South countries have repeatedly gone along with agendas and timelines set for them by others. 

There are many other fault lines within this process. Take the concept of efficiency, for example. What does it actually mean? Is it simply about austerity and cutting costs? Or could efficiency also mean directing more financing towards public institutions in Global South countries? We could move beyond the rhetoric of strengthening health systems and actually invest in public health systems that are accountable to the people they serve. 

Another fault line concerns how we understand global health security. Looking at the task force's terms of reference, I get the impression that global health governance reform is being framed largely around global health security. At the moment, global health security tends to be understood in relatively narrow terms: data surveillance, pathogen access and emergency preparedness. When we talk about preparedness in the Global South, the emphasis is often on building capacity, including training more health workers. But there is much less discussion about creating the conditions that would allow those health workers to stay in their countries. Without that, we risk reinforcing brain drain towards the Global North.

There are many issues that deserve to be discussed. But I'm not sure whether this process will make space for them, because these are not merely technical disagreements. Ultimately, they are political questions about accountability, solidarity and what it means to keep one another safe.

Looking at today's global health system, where do you see the greatest need for reform?

Dian: If the aim is to better align global health financing, then perhaps this is an opportunity to discuss how countries can coordinate the large number of externally funded projects more effectively.

We need to discuss how donors continue to shape national health priorities through their funding decisions, and what safeguards this reform process could establish to prevent donor interests from overriding countries' own priorities.

Of course, public development assistance is also influenced by political interests. But political interests are not necessarily selfish; they can also reflect a genuine desire to strengthen relationships between countries and support one another. With private interests, the dynamics can be quite different. Commercial actors may be primarily concerned with generating profits, including in sectors where business models can contribute to ill health. This makes safeguards against conflicts of interest and undue influence particularly important. I think establishing such safeguards should be a central focus of the reform process.

This also brings us back to the need to strengthen WHO and its core public health functions. We need to discuss how WHO can reduce its dependence on private donors and tightly earmarked voluntary contributions, which can constrain its ability to set its own priorities.

Another issue is the need for more predictable financing. If WHO itself cannot provide all the funding countries need, we should explore other mechanisms that can deliver reliable, accessible and sufficiently flexible resources when they are needed. 

So, for me, a key priority should be to explore mechanisms that strengthen not only WHO's independence but also countries' fiscal and technological autonomy. And if we are serious about global health security, we need to ask what it takes to enable countries to sustainably finance, govern and develop their own health systems and technological capacities.

Which priorities do you feel are still missing from current reform discussions?

Dian: Many countries across the Global South would agree that several key priorities remain insufficiently visible in this process. These include fiscal space, debt, and how global health reform connects with broader efforts to reform international financial governance. 

Another major disappointment is the lack of a serious agenda for discussing technology transfer, intellectual property and strengthening regional manufacturing capacity. If we want to talk about health sovereignty, we need to understand what it actually means for countries in the Global South. It means having the capacity to ensure reliable and equitable access to health products, as well as the ability to manufacture them nationally and regionally. 

I also think we need to pay much closer attention to how external financing affects domestic institutions, including public institutions. The question is not simply how much money flows into a country or how much development assistance it receives. We also need to ask through which channels the funding is delivered, which actors are involved, who benefits from these arrangements, whose priorities they advance, and whether they actually build lasting public capacity within countries.

What role can civil society play in the reform process?

Dian: I think civil society can do what it has always done best: make power visible. We need to ask who is driving this process, whose interests it serves, and who stands to benefit from its outcomes.

We can work together to monitor the process, conduct interviews, follow Member States' positions closely, and ensure that civil society and academia have timely, reliable information about what's happening. Civil society organisations and researchers are already working on issues such as debt, trade, intellectual property, climate justice and labour rights. We need to bring these different strands of work together and develop proposals that we can take directly to Member States and WHO.

The voices of communities, health workers, researchers and civil society experts in the Global South need to be heard. There is a wealth of knowledge, experience and concrete recommendations in these communities that WHO would lose out on if they are not given sufficient space and time to contribute meaningfully to the process.

And there is one final message I would particularly emphasise to civil society and academia: we must not allow ourselves to be used to legitimise decisions we have had no meaningful opportunity to shape. By participating in processes that offer the appearance of inclusion without giving us real influence, we risk inadvertently legitimising arrangements that preserve existing power structures and advance the interests of powerful actors, while shifting the consequences onto countries in the Global South and already marginalised populations.

We need to protect our independence and be clear about the difference between being consulted and having the power to influence decisions.

If there were one message you would want decision-makers involved in the reform process to hear, what would it be?

Dian: My message would be: Do not confuse coordination with transformation. There is a lot of confusion surrounding this process and its agenda. I am not particularly optimistic. At its core, this seems to be a technical exercise aimed at helping existing institutions and initiatives coordinate and work together more effectively, without necessarily challenging the underlying structures of power or addressing the interests they serve.

Further reading: In a July 2026 article for the Third World Network, “WHO: Reforming Global Health Architecture on Whose Terms?”, Dian critically analysed the WHO-led Global Health Architecture reform process and its implications for Global South participation and power.