The analogy with an orchestra is a good one and can be developed further. When we attend our local music hall and listen to a musical masterpiece we are witnessing the talents and commitments of many contributors who come together to present the perfect symphony, opera or ballet. In relation to Global Health, the audience is the millions of people worldwide who expect to receive the best possible healthcare. Continuing the orchestra analogy, they will want to know who composed the music, who is conducting the orchestra, and how all the musicians and their instruments have collectively delivered a perfect performance.
Sadly, Global Infant Feeding Policy does not provide a perfect performance and serves as an example of a dictatorial non-functioning orchestra. Briefly, here are some examples.
In 2023 WHO arranged a meeting described as the first Global Congress on the implementation of the 1981 International Code of Marketing of Breastmilk Substitutes. Unfortunately, at this long awaited review, WHO and UNICEF “selected” and “vetted” delegates to ensure they did not have a conflict of interest, especially “ties” with industry and some delegates were subsequently disinvited [1]. Does this filtering of opinion reflect the principles of the United Nations Committee on the Rights of the Child (UNCRC) and in particular the importance of non-discrimination and the right to be heard? It is noted that the introductory presentation was delivered by the Director-General of WHO.
The 2023 WHO Guideline for Complementary Feeding was heavily criticised in a joint publication from several health related societies and a key concern was the lack of consultation [2,3]. The WHO response to this concern was that “The societies… object to the fact that the guidelines were not subject to an open consultation process before publication. Public comment is not a usual practice for WHO guidelines and poses significant challenges for managing conflicts of interest, particularly on guidelines with implications for the sale of commercial products” [4]. This dismissal of the need for public consultation is discriminatory and appears to reflect a failure or unwillingness to manage differences of opinion. It is noted in the WHO Handbook for Guideline Development 2nd ed. 2014, that “Standard guidelines usually take between 9 and 24 months to complete, depending on their scope, and should be prepared after wide consultation on their need, scope and rationale”.
In 2023 a systematic review that was commissioned by WHO as part of the complementary feeding guideline, reported that there were no significant additional health benefits for the infant or for the mother from breastfeeding beyond12 months [2]. This conclusion was also reached by the Scientific Advisory Committee for Nutrition that advises the United Kingdom government [5]. However, despite this confirmatory evidence the WHO Complementary Feeding Guideline reaffirmed the view that breastfeeding for 2 years or beyond is a strong WHO recommendation and this was despite their acknowledgment that the evidence was graded as very low certainty [2]. Do governments and therefore parents act in accordance with WHO assertions or should they choose the scientific evidence? In this debate where is the governance perspective? Does the WHO complementary feeding document meet the UNCRC principles? Or does it reflect self-interest and lack of transparency?
In the 2023 complementary feeding document WHO also recommended that infants who are not being breastfed may be commenced on cow’s milk at 6 months, despite well documented health concerns relating to the introduction of cow’s milk in the first year of life which include iron deficiency, anaemia and gastrointestinal blood loss. [2] No new evidence was provided to support this change in policy. The clinical presentation of an infant passing blood is one that must always be taken seriously as it may be heralding a life threatening clinical condition. Is this an attempt to limit the infant formula market at the expense of the health of infants and the expressed wish from parents that they have an official safety net for lactation failure?
It is concluded that infant feeding remains a contentious global issue. The UNCRC is an essential document for ensuring that parents and their children are protected and supported. Current global infant feeding policy documents do not meet the principles or the spirit of UNCRC and therefore do not merit legislative status. An independent review is urgently required with the objective of providing a global policy/architecture for infant and young child feeding. With there now being a deep seated mistrust between infant feeding stakeholders a new approach should recognise that trust is not only a fundamental principle for change but it is also a fundamental right for infants and their parents.
Returning to the orchestra, the architecture of this particular global health responsibility lacks independent composers, inclusive conductors, an appropriate range of musicians and their instruments, and an appreciative audience.
2. WHO Guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO
3. European Society for Paediatric Gastroenterology, Hepatology & Nutrition(ESPGHAN), European Academy of Paediatrics(EAP), European Society for Paediatric Research(ESPR), et al. World Health Organization (WHO)guideline on the complementary feeding of infants and young children aged 6−23 months 2023: a multisociety response. J Pediatr Gastroenterol Nutr.2024;1‐8. doi:10.1002/jpn3.122488
4. Grummer-Strawn LM, Lutter CK, Siegfried N, Rogers LM, Alsumaie M, Aryeetey R, Baye K, Bhandari N, Dewey KG, Gupta A, Iannotti L, Pérez-Escamilla R, de Castro IRR, Wieringa FT, Yang Z. Response to: World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6-23 months 2023: A multisociety response. J Pediatr Gastroenterol Nutr. 2024 Nov;79(5):1084-1086. doi: 10.1002/jpn3.12363. Epub 2024 Sep 12. PMID: 39263990.
Thank you Stewart for this very detailed comment. It does help to look at specific areas like this — and to have well thought out critical takes. To extend the orchestra metaphor, you’re a music critic!
Your key point - "Any reform of the global health architecture must take into account how to connect the structure and process of the global health system to results." What would drive this, I presume, would be a coalition of national decision makers that would work to carry this out for at least this coalition subset. Alan
Enhancing Country-Integrated Accountability with NHA Framework (SHA 2011)
Date: Tuesday, July 22, 2025
Context
The global health ecosystem faces profound fragmentation and misaligned incentives among agencies, hindering strategic coordination and country ownership. Leveraging National Health Accounts (NHA) aligned with SHA 2011 standards offers a vital pathway to unify health expenditure tracking, improve transparency, and enhance inter-agency procurement accountability. This role-skills mapping articulates the technical and institutional capacities required to achieve these goals, informed by longstanding challenges in global procurement coordination.
Here is a web-friendly formatted matrix based on our detailed role skills mapping aligned with NHA frameworks, accompanied by explanatory text that incorporates the narrative’s key insights on global health architecture fragmentation and accountability challenges:
## Strategic Role Skills Mapping for Country-Integrated Accountability Using NHA Framework (SHA 2011)
| Inventory of all health expenditure sources | MoH (UNDP/WHO) | National health expenditure register | Data mapping, stakeholder engagement, documentation, public financial management | Creates a comprehensive, transparent register of all funding sources—including government, donors, private sector, insurance, and out-of-pocket—forming the basis for completeness and accountability. |
| Common expenditure classification / standardization | MoH / Finance (WHO / UNDP) | SHA 2011 codebook & mapping tools | Financial analytics, SHA technical expertise, budget policy analysis, classification | Harmonizes budget and procurement categories into SHA 2011 standards, enabling precise segregation of expenditures by agency and fund source and enhancing cross-agency consistency. |
| Capacity development in data, procurement, and reporting | MoH (UNDP expert roster) | UNDP eLearning platforms, in-country expert deployment | Training facilitation, procurement literacy, monitoring & evaluation, IT skills | Builds and sustains local skills to ensure data quality, procurement oversight, and reliable reporting aligned with NHA and SHA frameworks, empowering national systems. |
| Technology and data systems integration | MoH / IT (UNDP / WHO) | Digital public infrastructure toolkit, real-time dashboards | Systems integration, API management, cybersecurity, data visualization | Enables real-time mapping of procurement transactions, data interoperability across agencies, and integrity crucial for timely, harmonized national health accounts and joint procurement decisions. |
| Data responsibility matrix (cross-cutting) | MoH / NHA office (UNDP TS) | Data entry/validation protocols, workflow standards | Data stewardship, compliance monitoring, institutional relationship management | Assigns explicit accountability for each step of data entry, validation, and reporting, minimizing duplication, ambiguity, and loss of accountability across the health financing ecosystem. |
Despite decades of incremental technical progress, a critical barrier remains—the lack of structural incentives and mandates within agency leadership to collaborate under a unified, performance-based framework. This fragmentation hampers the system’s efficiency, transparency, and ability to adapt strategically in times when coordinated action is most needed.
The National Health Accounts (NHA) framework, anchored in SHA 2011, offers a robust technical foundation to address these challenges by standardizing expenditure classification, harmonizing data sources, and enabling precise segregation of health spending across government, donors, and private actors.
However, the true power of NHA lies not just in harmonized codebooks or digital tools, but in clear institutional roles and data stewardship backed by enforceable accountability.
This mapping underscores the necessity of empowered national Ministries of Health and Finance to lead comprehensive inventory and harmonization of all health financing sources and expenditures. Supported by partners such as UNDP and WHO, building capacity in both human resources and technology systems ensures national ownership and sustainability.
Critical is assigning a clear data responsibility matrix to eliminate ambiguities that have long caused duplicated procurement, fragmented accountability, and donor-driven reporting silos.
The cost of inertia and disconnected systems is enormous:
- Wasted resources and duplicated procurement efforts.
- Opaque fund flows that undermine governments’ strategic oversight.
- Delayed responses to urgent health needs.
- Eroded country ownership over national health financing.
Lessons from over 15 years since early inter-agency procurement initiatives demonstrate that technical feasibility alone is insufficient without leadership commitment to shift from agency branding to collective impact grounded in transparent performance frameworks.
Only through systematic implementation of this role skills mapping—integrating SHA-standardized data, capacity development, technology enabling real-time mapping, and joint reporting coupled with enforced accountability—can the global health “orchestra” finally play in tune.
This roadmap is a critical lever toward efficiency, trust, and sustainability precisely when the world faces tightening resources and escalating health demands.
Yes to more regional leadership. Yes to innovation scaling. Yes to restoring U.S. leadership — but in service of a multilateralism that listens more and dictates less. This is why we launched the Kigali Call to Action this past week at IAS - it includes five simple principles for the future: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)01427-8/fulltext
The time has come—and the urgency is clear—to move expeditiously in reforming, yes, downsizing, the global public health architecture. Peter’s observations are timely and point in the right direction: we must eliminate duplication and unnecessary competition for increasingly scarce resources. The current proliferation of agencies performing overlapping functions is no longer justifiable.
In any system built for results and accountability, success should eventually lead to the sunset of agencies that have fulfilled their original mandates. Yet too often, mission creep becomes a strategy for institutional survival. Rather than phasing out or consolidating, agencies expand their scope—regardless of whether such expansion aligns with comparative advantage or addresses actual gaps.
Take the Global Fund, for example, complementing Peter’s example. It has delivered measurable results in its original mission to combat HIV/AIDS, tuberculosis, and malaria. However, its more recent foray into broader health systems development overlaps with efforts already underway by institutions with deeper expertise in this area.
Gavi, likewise, has played an important global role in vaccine delivery. But its continued expansion raises questions of relevance and necessity in specific regional contexts. In the Americas, for instance, the PAHO Revolving Fund for Vaccines has long demonstrated a strong track record, delivering consistent results with regional ownership and accountability. Do the Americas need Gavi’s parallel structure? The answer is no. See for example post on the work of Dr. Ciro de Quadros, a Brazilian epidemiologist who was part of the smallpox eradication effort in Ethiopia and later led the Pan American Health Organization (PAHO)-driven polio-free initiative in the Americas.
Similarly, in Africa, the regional arrangements developed during the COVID-19 pandemic—including the Africa CDC and pooled procurement mechanisms—produced timely and effective results, without controversies! These regionally grounded initiatives show that new global layers are not always needed and may, in fact, hinder rather than help.
It is time for a more rational, streamlined, and accountable global public health ecosystem—one that builds on comparative advantage, supports regional and country leadership and ownership, and is willing to end institutions that have served their purpose.
Thank you, Peter, for this thoughtful and provocative reflection on the state of the global health architecture. I greatly appreciate how you highlight the opportunities for enhanced accountability, stronger focus on results, and improved efficiency at a time when resources are scarce and expectations are rising. Your call to bring country voices to the center through mechanisms like the SDG3 GAP survey resonates deeply, as does your emphasis on connecting governance and management reforms to measurable health outcomes.
I also value your reference to WHO’s Delivery for Impact approach - a practical method to link multilateral outputs to real results in countries. Embedding such dashboards and accountability loops into joint work plans and board discussions could indeed help the “orchestra” play in harmony, while still allowing for healthy performance‑based competition.
Your proposals offer a timely blueprint for how the system can evolve: country‑led, results‑driven, innovation‑powered, and productivity‑enhancing, so that we can collectively deliver more impact for every dollar invested. Thank you for stimulating this important conversation.
Global Health Architecture
The analogy with an orchestra is a good one and can be developed further. When we attend our local music hall and listen to a musical masterpiece we are witnessing the talents and commitments of many contributors who come together to present the perfect symphony, opera or ballet. In relation to Global Health, the audience is the millions of people worldwide who expect to receive the best possible healthcare. Continuing the orchestra analogy, they will want to know who composed the music, who is conducting the orchestra, and how all the musicians and their instruments have collectively delivered a perfect performance.
Sadly, Global Infant Feeding Policy does not provide a perfect performance and serves as an example of a dictatorial non-functioning orchestra. Briefly, here are some examples.
In 2023 WHO arranged a meeting described as the first Global Congress on the implementation of the 1981 International Code of Marketing of Breastmilk Substitutes. Unfortunately, at this long awaited review, WHO and UNICEF “selected” and “vetted” delegates to ensure they did not have a conflict of interest, especially “ties” with industry and some delegates were subsequently disinvited [1]. Does this filtering of opinion reflect the principles of the United Nations Committee on the Rights of the Child (UNCRC) and in particular the importance of non-discrimination and the right to be heard? It is noted that the introductory presentation was delivered by the Director-General of WHO.
The 2023 WHO Guideline for Complementary Feeding was heavily criticised in a joint publication from several health related societies and a key concern was the lack of consultation [2,3]. The WHO response to this concern was that “The societies… object to the fact that the guidelines were not subject to an open consultation process before publication. Public comment is not a usual practice for WHO guidelines and poses significant challenges for managing conflicts of interest, particularly on guidelines with implications for the sale of commercial products” [4]. This dismissal of the need for public consultation is discriminatory and appears to reflect a failure or unwillingness to manage differences of opinion. It is noted in the WHO Handbook for Guideline Development 2nd ed. 2014, that “Standard guidelines usually take between 9 and 24 months to complete, depending on their scope, and should be prepared after wide consultation on their need, scope and rationale”.
In 2023 a systematic review that was commissioned by WHO as part of the complementary feeding guideline, reported that there were no significant additional health benefits for the infant or for the mother from breastfeeding beyond12 months [2]. This conclusion was also reached by the Scientific Advisory Committee for Nutrition that advises the United Kingdom government [5]. However, despite this confirmatory evidence the WHO Complementary Feeding Guideline reaffirmed the view that breastfeeding for 2 years or beyond is a strong WHO recommendation and this was despite their acknowledgment that the evidence was graded as very low certainty [2]. Do governments and therefore parents act in accordance with WHO assertions or should they choose the scientific evidence? In this debate where is the governance perspective? Does the WHO complementary feeding document meet the UNCRC principles? Or does it reflect self-interest and lack of transparency?
In the 2023 complementary feeding document WHO also recommended that infants who are not being breastfed may be commenced on cow’s milk at 6 months, despite well documented health concerns relating to the introduction of cow’s milk in the first year of life which include iron deficiency, anaemia and gastrointestinal blood loss. [2] No new evidence was provided to support this change in policy. The clinical presentation of an infant passing blood is one that must always be taken seriously as it may be heralding a life threatening clinical condition. Is this an attempt to limit the infant formula market at the expense of the health of infants and the expressed wish from parents that they have an official safety net for lactation failure?
It is concluded that infant feeding remains a contentious global issue. The UNCRC is an essential document for ensuring that parents and their children are protected and supported. Current global infant feeding policy documents do not meet the principles or the spirit of UNCRC and therefore do not merit legislative status. An independent review is urgently required with the objective of providing a global policy/architecture for infant and young child feeding. With there now being a deep seated mistrust between infant feeding stakeholders a new approach should recognise that trust is not only a fundamental principle for change but it is also a fundamental right for infants and their parents.
Returning to the orchestra, the architecture of this particular global health responsibility lacks independent composers, inclusive conductors, an appropriate range of musicians and their instruments, and an appreciative audience.
References
1. WHO. Global Congress on implementation of the International Code of Marketing of Breastmilk Substitutes. 2023. https://www.who.int/publications/m/item/global-congress-on-implementation-of-the-international-code-of-marketing-of-breast-milk-substitutes
2. WHO Guideline for complementary feeding of infants and young children 6–23 months of age. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO
3. European Society for Paediatric Gastroenterology, Hepatology & Nutrition(ESPGHAN), European Academy of Paediatrics(EAP), European Society for Paediatric Research(ESPR), et al. World Health Organization (WHO)guideline on the complementary feeding of infants and young children aged 6−23 months 2023: a multisociety response. J Pediatr Gastroenterol Nutr.2024;1‐8. doi:10.1002/jpn3.122488
4. Grummer-Strawn LM, Lutter CK, Siegfried N, Rogers LM, Alsumaie M, Aryeetey R, Baye K, Bhandari N, Dewey KG, Gupta A, Iannotti L, Pérez-Escamilla R, de Castro IRR, Wieringa FT, Yang Z. Response to: World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6-23 months 2023: A multisociety response. J Pediatr Gastroenterol Nutr. 2024 Nov;79(5):1084-1086. doi: 10.1002/jpn3.12363. Epub 2024 Sep 12. PMID: 39263990.
5. Scientific Advisory Committee on Nutrition. Feeding young children aged 1-5 years. London. Gov.UK; 2023 https://www.gov.uk/government/groups/scientific-advisory-committee-on-nutrition
Thank you Stewart for this very detailed comment. It does help to look at specific areas like this — and to have well thought out critical takes. To extend the orchestra metaphor, you’re a music critic!
Your key point - "Any reform of the global health architecture must take into account how to connect the structure and process of the global health system to results." What would drive this, I presume, would be a coalition of national decision makers that would work to carry this out for at least this coalition subset. Alan
Absolutely. It all comes down to governance. https://open.substack.com/pub/singerp/p/who-governance-from-resolutions-to?r=1ytch0&utm_medium=ios
Enhancing Country-Integrated Accountability with NHA Framework (SHA 2011)
Date: Tuesday, July 22, 2025
Context
The global health ecosystem faces profound fragmentation and misaligned incentives among agencies, hindering strategic coordination and country ownership. Leveraging National Health Accounts (NHA) aligned with SHA 2011 standards offers a vital pathway to unify health expenditure tracking, improve transparency, and enhance inter-agency procurement accountability. This role-skills mapping articulates the technical and institutional capacities required to achieve these goals, informed by longstanding challenges in global procurement coordination.
Here is a web-friendly formatted matrix based on our detailed role skills mapping aligned with NHA frameworks, accompanied by explanatory text that incorporates the narrative’s key insights on global health architecture fragmentation and accountability challenges:
## Strategic Role Skills Mapping for Country-Integrated Accountability Using NHA Framework (SHA 2011)
| **Workstream & Key Outputs** | **Lead / Support** | **Key Tools & Frameworks** | **Essential Skills & Capacities** | **NHA Relevance & Accountability Impact** |
|-----------------------------------------------|-----------------------------|-----------------------------------------------|-------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------|
| Inventory of all health expenditure sources | MoH (UNDP/WHO) | National health expenditure register | Data mapping, stakeholder engagement, documentation, public financial management | Creates a comprehensive, transparent register of all funding sources—including government, donors, private sector, insurance, and out-of-pocket—forming the basis for completeness and accountability. |
| Common expenditure classification / standardization | MoH / Finance (WHO / UNDP) | SHA 2011 codebook & mapping tools | Financial analytics, SHA technical expertise, budget policy analysis, classification | Harmonizes budget and procurement categories into SHA 2011 standards, enabling precise segregation of expenditures by agency and fund source and enhancing cross-agency consistency. |
| Capacity development in data, procurement, and reporting | MoH (UNDP expert roster) | UNDP eLearning platforms, in-country expert deployment | Training facilitation, procurement literacy, monitoring & evaluation, IT skills | Builds and sustains local skills to ensure data quality, procurement oversight, and reliable reporting aligned with NHA and SHA frameworks, empowering national systems. |
| Technology and data systems integration | MoH / IT (UNDP / WHO) | Digital public infrastructure toolkit, real-time dashboards | Systems integration, API management, cybersecurity, data visualization | Enables real-time mapping of procurement transactions, data interoperability across agencies, and integrity crucial for timely, harmonized national health accounts and joint procurement decisions. |
| Joint reporting & feedback loops | MoH (Global Fund/Donors) | Annual SHA-based reports, online feedback surveys | Report writing, multi-stakeholder coordination, survey design and analysis | Facilitates transparent multi-agency expenditure reporting aligned with SHA, enabling dynamic feedback to improve inter-agency alignment, policy responsiveness, and accountability mechanisms. |
| Data responsibility matrix (cross-cutting) | MoH / NHA office (UNDP TS) | Data entry/validation protocols, workflow standards | Data stewardship, compliance monitoring, institutional relationship management | Assigns explicit accountability for each step of data entry, validation, and reporting, minimizing duplication, ambiguity, and loss of accountability across the health financing ecosystem. |
Despite decades of incremental technical progress, a critical barrier remains—the lack of structural incentives and mandates within agency leadership to collaborate under a unified, performance-based framework. This fragmentation hampers the system’s efficiency, transparency, and ability to adapt strategically in times when coordinated action is most needed.
The National Health Accounts (NHA) framework, anchored in SHA 2011, offers a robust technical foundation to address these challenges by standardizing expenditure classification, harmonizing data sources, and enabling precise segregation of health spending across government, donors, and private actors.
However, the true power of NHA lies not just in harmonized codebooks or digital tools, but in clear institutional roles and data stewardship backed by enforceable accountability.
This mapping underscores the necessity of empowered national Ministries of Health and Finance to lead comprehensive inventory and harmonization of all health financing sources and expenditures. Supported by partners such as UNDP and WHO, building capacity in both human resources and technology systems ensures national ownership and sustainability.
Critical is assigning a clear data responsibility matrix to eliminate ambiguities that have long caused duplicated procurement, fragmented accountability, and donor-driven reporting silos.
The cost of inertia and disconnected systems is enormous:
- Wasted resources and duplicated procurement efforts.
- Opaque fund flows that undermine governments’ strategic oversight.
- Delayed responses to urgent health needs.
- Eroded country ownership over national health financing.
Lessons from over 15 years since early inter-agency procurement initiatives demonstrate that technical feasibility alone is insufficient without leadership commitment to shift from agency branding to collective impact grounded in transparent performance frameworks.
Only through systematic implementation of this role skills mapping—integrating SHA-standardized data, capacity development, technology enabling real-time mapping, and joint reporting coupled with enforced accountability—can the global health “orchestra” finally play in tune.
This roadmap is a critical lever toward efficiency, trust, and sustainability precisely when the world faces tightening resources and escalating health demands.
[1] https://www.globalhealthhub.de/en/news/detail/the-global-health-talk-2025-opportunities-for-global-health-in-times-of-crisis
[2] https://www.cgdev.org/topics/reforming-global-health-architecture
[3] https://www.gavi.org/news/media-room/gavi-statement-global-health-architecture
[4] https://www.worldhealthsummit.org/events/annual-whs/2025/central-topics
[5] https://www.cgdev.org/blog/time-change-reforming-global-health-architecture
[6] https://www.globalgovernanceproject.org/integrating-global-health-governance-for-a-fragmented-world/john-kirton/
[7] https://pmc.ncbi.nlm.nih.gov/articles/PMC11931954/
[8] https://www.bcg.com/publications/2025/global-health-system-calls-for-new-models
[9] https://pmc.ncbi.nlm.nih.gov/articles/PMC11784496/
[10] https://international-partnerships.ec.europa.eu/document/download/d72047b7-b83c-4a49-9c6a-3c7e765831b4_en?filename=Indicative+programme+and+concept+note.pdf
Indeed. The tools are there. But leadership needs to be relentlessly focussed on results. https://open.substack.com/pub/singerp/p/un-leadership-relentlessly-focused?r=1ytch0&utm_medium=ios
Yes to more regional leadership. Yes to innovation scaling. Yes to restoring U.S. leadership — but in service of a multilateralism that listens more and dictates less. This is why we launched the Kigali Call to Action this past week at IAS - it includes five simple principles for the future: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)01427-8/fulltext
The time has come—and the urgency is clear—to move expeditiously in reforming, yes, downsizing, the global public health architecture. Peter’s observations are timely and point in the right direction: we must eliminate duplication and unnecessary competition for increasingly scarce resources. The current proliferation of agencies performing overlapping functions is no longer justifiable.
In any system built for results and accountability, success should eventually lead to the sunset of agencies that have fulfilled their original mandates. Yet too often, mission creep becomes a strategy for institutional survival. Rather than phasing out or consolidating, agencies expand their scope—regardless of whether such expansion aligns with comparative advantage or addresses actual gaps.
Take the Global Fund, for example, complementing Peter’s example. It has delivered measurable results in its original mission to combat HIV/AIDS, tuberculosis, and malaria. However, its more recent foray into broader health systems development overlaps with efforts already underway by institutions with deeper expertise in this area.
Gavi, likewise, has played an important global role in vaccine delivery. But its continued expansion raises questions of relevance and necessity in specific regional contexts. In the Americas, for instance, the PAHO Revolving Fund for Vaccines has long demonstrated a strong track record, delivering consistent results with regional ownership and accountability. Do the Americas need Gavi’s parallel structure? The answer is no. See for example post on the work of Dr. Ciro de Quadros, a Brazilian epidemiologist who was part of the smallpox eradication effort in Ethiopia and later led the Pan American Health Organization (PAHO)-driven polio-free initiative in the Americas.
https://open.substack.com/pub/pmarquez/p/how-to-strengthen-vaccination-for?r=12a3te&utm_medium=ios
Similarly, in Africa, the regional arrangements developed during the COVID-19 pandemic—including the Africa CDC and pooled procurement mechanisms—produced timely and effective results, without controversies! These regionally grounded initiatives show that new global layers are not always needed and may, in fact, hinder rather than help.
It is time for a more rational, streamlined, and accountable global public health ecosystem—one that builds on comparative advantage, supports regional and country leadership and ownership, and is willing to end institutions that have served their purpose.
Patricio V Márquez
Excellent examples and arguments. Thank you Patricio.
Thank you, Peter, for this thoughtful and provocative reflection on the state of the global health architecture. I greatly appreciate how you highlight the opportunities for enhanced accountability, stronger focus on results, and improved efficiency at a time when resources are scarce and expectations are rising. Your call to bring country voices to the center through mechanisms like the SDG3 GAP survey resonates deeply, as does your emphasis on connecting governance and management reforms to measurable health outcomes.
I also value your reference to WHO’s Delivery for Impact approach - a practical method to link multilateral outputs to real results in countries. Embedding such dashboards and accountability loops into joint work plans and board discussions could indeed help the “orchestra” play in harmony, while still allowing for healthy performance‑based competition.
Your proposals offer a timely blueprint for how the system can evolve: country‑led, results‑driven, innovation‑powered, and productivity‑enhancing, so that we can collectively deliver more impact for every dollar invested. Thank you for stimulating this important conversation.
Thanks. Let’s see if it can happen.