The Global Health Architecture: Governance and International Institutions to Advance Population Health Worldwide

Centennial Issue
Global Health

Policy Points:

  • Global health institutions and instruments should be reformed to fully incorporate the principles of good health governance: the right to health, equity, inclusive participation, transparency, accountability, and global solidarity. New legal instruments, like International Health Regulations amendments and the pandemic treaty, should be grounded in these principles of sound governance.
  • Equity should be embedded into the prevention of, preparedness for, response to, and recovery from catastrophic health threats, within and across nations and sectors. This includes the extant model of charitable contributions for access to medical resources giving way to a new model that empowers low- and middle-income countries to create and produce their own diagnostics, vaccines, and therapeutics—such as through regional messenger RNA vaccine manufacturing hubs.
  • Robust and sustainable funding of key institutions, national health systems, and civil society will ensure more effective and just responses to health emergencies, including the daily toll of avoidable death and disease disproportionately experienced by poorer and more marginalized populations.

The United Nations (UN) created the World Health Organization (WHO) as its first specialized agency out of the ruins and atrocities of World War II. For decades after its creation, the WHO had an unrivaled place leading world health at the very center of the global health architecture. In those early years, the WHO was one of very few institutions in the health space, later joined by the World Bank. By 1980, the WHO achieved the unimaginable—the eradication of the ancient scourge of smallpox. But the WHO’s power and influence has steadily waned, with a plethora of global institutions and actors entering the space that the WHO alone had once occupied.

Following the West African Ebola epidemic (2014-2016), the WHO enacted several key reforms, notably the creation of its Health Emergencies Programme and a Contingency Fund for Emergencies. However, the COVID-19 pandemic was a turning point for the WHO. The agency found itself embroiled in a bitter political dispute between two superpowers, China and the United States, culminating in former President Trump’s announcement that the United States would withdraw from the WHO. During COVID-19, the WHO’s leadership was called into question, and governments largely failed to comply with the International Health Regulations (2005) (IHR) while disregarding WHO recommendations under the IHR. This precipitated a series of audacious reform proposals. The World Health Assembly (WHA) charged an Intergovernmental Negotiating Body with negotiating and codifying a new international instrument for pandemic prevention, preparedness, response, and recovery, often referred to as a pandemic treaty.


Gostin LO, Friedman EA, and Finch A. Global Health Architecture: Governance and International Institutions to Advance Population Health Worldwide. Milbank Q. 2023;101(S1):734-769.