Intended for healthcare professionals


Reforming global health governance in the face of pandemics and war

BMJ 2022; 378 doi: (Published 13 September 2022) Cite this as: BMJ 2022;378:o2216
  1. Yuxuan Jiang1,
  2. Anthony Zhong2,
  3. Simar S Bajaj3,
  4. Gordon Guyatt45
  1. 1Michael G DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
  2. 2School of International Development and Global Studies, University of Ottawa, Ottawa, ON, Canada
  3. 3Department of the History of Science, Harvard University, Cambridge, MA, USA
  4. 4Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
  5. 5Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

When Russian tanks rolled into Ukraine in late February 2022, two years after the identification of SARS-CoV-2, the ensuing humanitarian crisis and upending of international law fractured the already fragile system of global health governance.

Many have elaborated on the immediate health effects of Russia’s invasion of Ukraine in the face of an ongoing pandemic. The long term effects on global health governance are, however, underappreciated. These unprecedented challenges to global health infrastructure highlight an urgent need for systemwide reforms.

The short term consequences of the war include more than 12 000 civilian casualties, 6.9 million refugees, the levelling of Ukrainian healthcare facilities, widespread food insecurity, and higher risks of cholera, polio, tuberculosis, and covid-19.1 Less noticeable and possibly more profound are the tectonic geopolitical shifts that threaten the foundations of global governance and, by extension, the international health system.

The invasion of Ukraine and the increasingly belligerent rhetoric between the US, Russia, and China signal a return to great power competition and balance-of-power politics. These hostilities could undermine years of global health progress and fragment the field by interfering with global health reporting, financing, and agenda setting through diplomatic spats and isolationism.2 Global health, which is inherently collaborative by nature, cannot function effectively in a divided world.

Undermining cooperation

The war and the pandemic have already revealed the costs of shifting away from globalism towards realpolitik. Rivalry for narrative control has inhibited rapid, truthful data sharing and impeded the work of the World Health Organization. The domestic relocation of high income countries’ medical supply chains, under the banner of health security, reduced the predictability and openness of the rules based trade system, disproportionately damaging low and middle income countries.3

Furthermore, cross national medical collaboration and innovation were compromised. Before the war, Ukraine was a global destination for validating pharmaceutical therapies, including covid-19 treatments, and was home to more than 400 ongoing clinical trials—all of which are now in limbo.4

If current trends prevail, great powers are likely to continue subordinating international responses to health threats in service of their national interests. This may involve both marginalising issues that do not align with their geostrategic priorities and actively undermining global health cooperation.2 Global health expenditures may also become a casualty of the world’s surging defence spending.5 All of these patterns bode poorly for future health crises.

In response to these mounting challenges, a renewed commitment to global health cooperation is necessary. If these geopolitical headwinds continue, we propose the following systemic reforms to ensure that the delivery of global public health goods continues unabated.

Stockpiling and supply

Firstly, accurate and timely epidemiological data are crucial. If health data continue to be viewed as a strategic advantage, global health responses will suffer. While international information sharing and transparency hold great importance, sporadic revelations of transmissible diseases on social media can predate and, at times, be more credible than official communiques from originating governments.6

Within this context, an open source intelligence collaborative for global public health monitoring that surveys the web, identifies early warning signs, and predicts health risks is needed for rapid response efforts. Until its abrupt defunding in 2019, Canada’s Global Public Health Intelligence Network serviced this role, using automated processes to monitor global media sources on a real time, 24/7 basis and providing early detection for international health threats (such as infectious disease outbreaks, bioterrorism, and contaminated food or water).7 The rapid re-establishment of an analogous organisation—one that is international and ideally disassociated from foreign intelligence agencies—could anchor global health cooperation.

Secondly, the increasing emphasis on medical supply chain security threatens to further monopolise already asymmetrical access to resources. While strategic national stockpiling has proved insufficiently agile for dynamic risks and global crises, whether wars or pandemics, the reality is that this trend towards hoarding and supply chain nationalism is likely to continue.8

Novel approaches are required to coordinate and satisfy future emergent global healthcare demands, particularly for countries without control over a substantial portion of their healthcare supply chains. Now, more than ever, WHO must go beyond nation states and also partner directly with industry to create a global coordinating centre for healthcare resources. Such a collaboration could document and share current inventories of critical medical supplies to rapidly resolve supply-demand discrepancies, tackle information asymmetries, and mitigate hoarding.9

For example, without requiring substantial additional resources, this partnership could match demands from a regional outbreak in northern Africa with existing supplies of ventilator stockpiles in a German warehouse and FedEx fleet capacity in an Egyptian airport, something previously impossible because of information opacity. Establishing greater visibility and sharing infrastructure that transcends governmental boundaries in peacetime would allow for rapid mobilisation of resources in times of need.

Regional organisations

Finally, greater emphasis must be placed on mobilising regional organisations in global public health responses. While the dual shock from covid-19 and the war in Ukraine has undermined globalisation, regionalisation is more likely to continue.10 The close integration between WHO and the Pan-American Health Organization can extend to other regional health organisations, including the Association of Southeast Asian Nations’ Health Sector and the African Union’s Division of Health. These organisations are more familiar with local policy conditions and are more capable of navigating regional geopolitical interests, thus being able to manoeuvre with greater agility and political consensus. Strengthening regional health institutions is a key facet for improving robustness in global health.

The experience of the past three years has generated key challenges for global health governance and an urgent need to adapt to the current order. Our failures of response during the pandemic and the war in Ukraine are manifestations of a world more encumbered with nationalism than mutualism. Reforming the fractured global health mechanisms of today will prepare us to face the inevitable crises of tomorrow.


YJ and AZ contributed equally to this manuscript as co-first authors. YJ and AZ conceptualised the manuscript. YJ, AZ, and SSB drafted the manuscript. GG provided supervision and editorial support. All authors read and approved the final draft before submission.


  • Competing interests: None.

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