Low- and middle-income countries have been calling for major overhauls in global health governance since the early 2000s. Initial funding from global health initiatives, such as Gavi and the Global Fund, was directed to specific diseases instead of building primary care. Even now, high-income countries focus on reforming global health architecture and adjusting donor workflows. Although those conversations are well-intentioned, regional voices should lead discussions around proposed changes in Africa to prevent any perpetuation of inequality of access to health services. The vertical response to HIV and AIDS, for example, overlooked other critical public-health arenas, such as chronic viral hepatitis and noncommunicable diseases.

In a Think Global Health piece from January, Ebere Okereke spotlighted two vulnerabilities in global health architecture: African countries lived through the consequences of health architecture designed around choices made elsewhere and reversed without notice. Second, the dismantling of the U.S. Agency for International Development (USAID) and massive funding cuts exposed how much of the global health system rests on discretion rather than durable assurance.

Those two points encapsulate the challenges Africa faces as it moves away from external aid.

Global health reform, however, presents an opportunity for the continent to own its narrative. African countries have accumulated decades of operational experience working with partners such as Gavi, the Global Fund, Unitaid, and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). That know-how offers governments an opportunity to leverage their experience in managing and implementing their countries' public-health programs to shape financing, governance, and accountability. The reconstruction of the global health architecture is not an abstract governance issue; it is directly linked to countries' ability to protect essential services, sustain gains, and improve population outcomes.

Global health reform, however, presents an opportunity for the continent to own its narrative

To transform implementation experience into evidence, countries should outline how the current architecture performs against key indicators such as alignment with national priorities, administrative burden, transaction costs, integration with primary health-care systems, sustainability, and impact on equity and service continuity.

African governments should use the evidence from field implementation to move toward stewardship. Agencies, such as the World Health Organization (WHO), will also need to adjust relationships at the country level to facilitate that shift. In practice, this means that global health architecture should be assessed by how it strengthens service delivery, system resilience, and return on investment. Discussions need to address whether people are receiving vaccines, whether medicines are reaching facilities, and whether health systems can still function when external support falls.

WHO Regional Office for Africa: Building on Practical Experience

African governments and organizations such as the WHO Regional Office for Africa and Africa Centres for Disease Control and Prevention (Africa CDC) already operate at the intersection of global financing and local delivery, managing vaccine programs; HIV, tuberculosis (TB), and malaria programs; disease surveillance systems; outbreak response; health workforce deployment; commodity chains; and community engagement.

That experience should influence structural reform, similar to how the WHO Transformation Agenda was developed and implemented in the region. By decentralizing partnership functions and engaging non-state actors, such as NGOs and the private sector, the agenda resulted in a shift from traditional resource mobilization to more collaborative partnerships, expanding the reach of health initiatives across diverse populations. These alliances have boosted the WHO Regional Office for Africa's capacity to mobilize resources and better support its member states to strengthen health systems and resilience, particularly during crises, such as the COVID-19 pandemic.

That shift also brought significant progress in a number of health areas in the African region in the past decade, as regional leadership has contributed to setting priorities, coordinating action, mobilizing resources, and encouraging strong political ownership of health goals. The Expanded Special Project for Elimination of NTDs (ESPEN), resulting from a recognition of the interrelatedness of neglected tropical diseases (NTDs), was launched in 2016.

Their work has contributed to elimination of multiple NTDs, including river blindness, Guinea worm disease, and trachoma, across the continent. Between 2017 and 2019, the time taken to detect outbreaks of epidemic-prone diseases decreased from 14 to 4 days, and the time it took to end an outbreak decreased by a third.

In the past 10 years, wild polio virus has been eradicated from sub-Saharan Africa; Cape Verde, Mauritius, and Seychelles have eliminated measles and rubella; vaccination has averted millions of deaths from vaccine-preventable diseases; malaria and human papilloma virus (HPV) vaccines have been introduced at scale; and the region is ramping up response to the growing burden of noncommunicable diseases through WHO PEN and PEN-Plus initiatives.

Health workers prepare to vaccinate infants at the Mother and Child Hospital in Kasoa, Ghana, on November 19, 2025. — Health workers prepare to vaccinate infants at the Mother and Child Hospital, in Kasoa, Ghana, on November 19, 2025. REUTERS/Francis Kokoroko

The Ending Disease in Africa (ENDISA) strategy, launched in 2023, was developed by the WHO to accelerate the shift from vertical disease-control programs to integrated, cross-cutting planning and implementation. The strategy is based on decades of lessons learned in preventing and controlling disease in Africa, as well as the core success factors of Africa's COVID-19 pandemic response that include strong coordination across the region and rapid scale-up of testing capacity.

ENDISA's four special initiatives—focusing on diversifying models of technical support, strengthening local institutional capacity, stimulating research and innovation, and scaling up the data required for evidence-based decision-making—were developed to strengthen country ownership of health programs, provide evidence for prioritization and policy, and specify a pathway to sovereignty, making the strategy particularly pertinent to discussions about the reform of global health architecture.

Additional shifts in programming caused by the aid cuts, such as condensing the WHO Regional Office for Africa's programming, strengthening its convening role, and streamlining technical support at the country level, have continued to use ENDISA as the underlying strategy.

Moving Forward

The current reform process is alive and not theoretical. In February 2026, the WHO executive board developed a joint, inclusive, member state–led process bridging current global health architecture and UN80 discussions [PDF]. That process provided a formal opportunity for countries to shape both the content of reform and the consolidation of ideas. Gavi has publicly stated that its reform agenda under Leap places countries at the center and seeks to simplify operational procedures and funding. Country-driven-reform arguments need to be organized and strategic to gain attention, by working within regional discussion groupings such as the annual WHO Regional Committee for Africa and the World Health Summit (WHS) regional meetings, taking place this year in Nairobi.

Africa bears disproportionate health burdens and remains marginalized in global health governance. Unless the WHO Regional Office for Africa, the African Union, and the Africa CDC act as convening platforms for countries as they navigate these changes, the continent risks remaining a passive recipient of multiple, converging reform tracks. Regional bodies should be empowered and resourced to codefine priorities and drive implementation grounded in African realities. Meaningful reform requires redistributing power based on the expertise and priorities of countries, not consolidation. The Accra Reset is an innovative platform to advance this structure.

Financing equitable health systems demands predictable, long-term funding. Africa needs to develop health finance and country-led integrated health compacts, building on examples such as Zambia's presidentially led roadmap toward universal health coverage, to optimize available financial resources. Additionally, Ethiopia, Kenya, Morocco, Nigeria, and Senegal are among 15 countries adopting the World Bank country compacts to accelerate progress toward affordable health services.

External partners should be held accountable through mechanisms anchored in existing, country-led governance and data systems, such as joint annual reviews, with fewer parallel mechanisms, reviewing partner performance against national health strategies, to work in alignment with the Lusaka Agenda. In a similar way, monitoring and evaluation (M&E) mechanisms should be defined against one national M&E framework, tied to national plans, and all partners reporting against the same indicators, based on core data from country systems, such as DHIS2 (District Health Information Software 2).

Prioritization of health needs cannot be done in a vacuum. It requires multisectoral collaboration to develop strategic national health plans that define a roadmap for each country. Africa needs to define its regional public-health goods—cross-border surveillance and data interoperability, regional lab networks and genomic surveillance, emergency workforce and stockpile, to name but a few. By defining these goods, Africa can prioritize country requirements and enlist multisectoral collaboration to build health systems.

Execution and implementation are key in resource-constrained contexts. Regional leadership should be accompanied by effective implementation mechanisms and structures on the ground.

African countries, organizations, and institutions need to take bold steps to ensure that Africa is a major partner and coauthor in the reform of global health architecture. Reform should center sovereignty, equity, and regional leadership.

World Health Organization workers prepare for an ebola vaccination campaign, in Mbandaka, Democratic Republic of Congo, on May 21, 2018. — World Health Organization workers prepare for an Ebola vaccination campaign, in Mbandaka, Democratic Republic of Congo, on May 21, 2018. REUTERS/Kenny Katombe

AUTHOR'S NOTE: We acknowledge with thanks the excellent research and writing support from Bridget Farham, scientific writer, WHO Regional Office for Africa, and the valuable input from Caroline Kantis, Think Global Health.

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