For years, reforming the global health system was a debate more theoretical than practical. A recurring topic in reports and expert forums, yet distant from the urgency of decision-making. Today that distance has disappeared. The contraction of international funding has turned reform into an immediate necessity, with direct implications for both public health and the financial sustainability of health systems.
This context has spurred numerous reform proposals, such as the one presented by the Spanish government at the recent International Conference held in Seville, which share diagnoses and common lines of action. All point to the need to mobilize more domestic resources, improve spending efficiency, rebalance priorities, and strengthen primary care by adapting it to the population’s real needs.
“Projections indicate that if this trend continues, nearly ten million additional deaths could occur by 2030”
Thus, organizations operating in the field of global health face complex decisions about priorities, mandates, and efficiency, while essential programs are scaled back or disappear. The consequences are already becoming visible, with disrupted treatments, halted prevention campaigns, and growing uncertainty among healthcare professionals as well as millions of people who find it harder to access basic services. Projections indicate that if this trend continues, nearly ten million additional deaths could occur by 2030. Beyond the human impact, this scenario signals mounting pressure on already strained national budgets.
Many of these proposals emphasize strengthening global public goods, the shared investments that generate collective benefits no country can guarantee on its own, such as regulatory standards, disease surveillance, the knowledge to produce medicines, or information on their prices. It is, essentially, about correcting structural faults that make systems more costly and reduce their ability to guarantee the right to health.
“Without a deliberate focus on access, decisions taken today under financial pressure may translate into fragmented markets, high prices, and inefficient allocation of public resources”
However, as these discussions progress, the debate risks focusing almost exclusively on institutional reorganization, consolidation of agencies or redefining mandates. While these measures may generate short-term efficiencies, they sideline a long-term health and economic question: how to ensure health innovation reaches people equitably and at affordable prices.
Without a deliberate focus on access, the decisions taken today under financial pressure may translate into fragmented markets, higher prices and an inefficient allocation of public resources.
The leadership of Pedro Sánchez’s government in equitable access to health innovation is not new. Since the pandemic, Spain has shown steady action and today stands among the few countries increasing their official development assistance.
Innovation has been one of the main drivers of health progress in recent decades. Advances in HIV treatment, the development of vaccines that have saved millions of lives, and the expansion of rapid diagnostics have strengthened health systems and contributed to economic growth. That journey also enabled an unprecedented scientific response to COVID-19.
However, innovation does not automatically translate into health impact or economic efficiency. New medicines, vaccines and technologies reach health systems through markets that prioritize the ability to pay, the available infrastructure and early demand. If these processes are not guided consciously, innovations will benefit first those who are already in a better position, widening inequalities between countries and generating higher costs in the medium to long term.
The case of lenacapavir is a good example. This long-acting injectable represents a meaningful advance in HIV prevention, by substantially reducing adherence barriers associated with existing methods. Without targeted intervention, its deployment would have followed a known pattern, with early access in high-income countries and prolonged delays in terms of price and availability in low- and middle-income countries, where a significant share of the disease burden is concentrated.
The experience was different because Unitaid, together with the Clinton Health Access Initiative (CHAI) and Wits RHI, tackled access from the outset. This early coordination and active market-shaping work enabled an unprecedented agreement with Dr. Reddy’s Laboratories: a price of $40 per person per year for 120 low- and middle-income countries. Beyond the health sector, this example shows that anticipating access can prevent market distortions, reduce prices, and improve the efficiency of public spending.
“Without deliberate action, even the most promising advances can fall out of reach for those who need them most”
This case is no exception. The same dynamic repeats across almost all areas of health innovation, and without deliberate action, even the most promising advances can remain out of reach for those who need them most. Correcting these market failures requires sustained long-term investments as well as taking risks from early stages, and coordinated global planning, with capacities that no single country can deploy alone. From an economic perspective, the objective is to prevent fragmentation and lack of scale from driving up the cost of solutions that could be more efficient.
Therefore, access cannot continue to be treated as a late addition nor as an occasional act of solidarity. It must be understood as a structural function of the global health system and financed as a global public good.
Nevertheless, these goods remain undervalued and underfunded, despite their potential to reduce costs and improve outcomes. At the same time, many countries are moving toward models of greater health self-sufficiency, driven by significant changes in the international aid landscape. This transition is legitimate and necessary. But without solid international cooperation that backs access to innovation as a collective good, each country faces in isolation complex negotiations and terms set by markets over which it has little influence. In that context, new technologies arrive later or on worse terms, and health progress loses momentum as gaps widen—the very disparities the global health system aims to reduce.
In light of such a scenario, multilateralism must adapt, not retreat. The future of global health requires mechanisms that accelerate access to innovation, reduce inefficiencies and align national and regional priorities. The experience shows this model works. Over the past twenty years, Unitaid has played a significant role in closing the gap between innovation and access, helping to bring more than one hundred health products to market with a return on investment of 46 euros for every euro invested, one of the most cost-effective models in global health.
We face an evident dilemma. We can continue to celebrate scientific advances while accepting fragmented markets and high prices that limit their impact. Or we can treat access to innovation as a shared investment, capable of improving the efficiency of public spending and strengthening the sustainability of health systems. With budget constraints on the table, this choice is as economic as it is health-related.
