Tag Archives: Global Health

A New Global Health Architecture: Maximising Health Returns

There have been a number of opinion pieces, resets, and declarations on what is needed in a new Global Health Architecture. These have been authored by diplomats, former Prime Ministers and Presidents, Multi-lateral agency staff and former staff, Philanthropies and peak bodies on what is needed in a new global health architecture. They have appeared in prestigious peer reviewed journals, on corporate websites, and here, I have attempted to synthesise the core messages and draw them together into an aggregate position that can help national governments action some of the ideas.

It starts with the contemporary global health landscape, which is increasingly defined by structural fiscal contraction, evolving geopolitical priorities, and the imperative to sustain health systems performance under conditions of constrained financing. In this context, legacy colonial models of development assistance—characterised by externally driven priorities, fragmented delivery channels, and open-ended commitments—are no longer fit for purpose. A transition toward more efficient, sovereign-aligned frameworks can deliver health at scale across well segmented population groups.

At the center of this transition is a reassertion of national sovereignty. Low- and low-middle income countries have historically been analysed through the lens of deficit-based models—most notably income, poverty and other World Bank style development indicators. In a context of increasing financial constraint and projected stagnation or decline in economic growth, that approach invites systemic failure.

A better alternative is an analysis of countries through the lens of asset-based models and indicators. This shift allows for a reorientation from needs-based allocation towards strategic engagement, in which financially flexible partners align with nationally defined priorities to co-develop fully costed health pathways. Such pathways provide end-to-end cost visibility, improving efficiency and accountability and enabling the precise calibration of health investments against projected returns. The well-established link between health improvement and economic productivity can be operationalised as part of national investment cases.

This reorientation will motivate a shift away from traditional sovereign lending, with its associated conditionalities, as the dominant financing modality. While sovereign lenders have played a critical role in expanding access and supporting system development, their balance sheets are increasingly constrained. Capital markets offer emerging mechanisms to complement sovereign financing in targeted areas where risk can be appropriately structured and priced. Through structured asset-pooling within and across countries, these mechanisms can enhance risk absorption and expand resource mobilisation. Over time, they may progressively relieve pressure on sovereign financing, enabling health systems to access more diversified funding streams while reducing exposure to fiscal volatility. This, in turn, may lessen reliance on sovereign conditionalities and allow national governments greater implementation flexibility.

Operationalising this shift requires the development of a coherent investment architecture. One approach is the development of Population Equity Units (PEUs), which serve as the foundational analytical and financial entities within national systems. These units can be aggregated into stratified Demographic Asset Classes, reflecting variations in projected lifetime contribution, health system utilisation, and responsiveness to intervention. The introduction of such classifications enables a more granular understanding of where investments are likely to generate the greatest returns for national governments alongside the highest health-valued gains.

To support decision-making across this architecture, a Health Returns Value Index (HRVI) can be employed. The Index would provide a standardised metric for comparing Population Equity Units based on anticipated health outcomes relative to cost. This facilitates outcome-weighted health investment prioritisation, ensuring that limited resources are allocated in a manner consistent with maximising aggregate health systems performance. Importantly, such an Index would allow for dynamic recalibration over time, as demographic, epidemiological, and economic conditions evolve.

Within this framework, national health systems can be conceptualised as Health Equity Portfolios. These portfolios comprise a diversified set of Population Equity Units across multiple Demographic Asset Classes, each contributing differently to overall system yield. Standard portfolio management principles can then be applied, including allocation, rebalancing, and risk mitigation. High-performing segments—those demonstrating strong alignment between investment and realised outcomes—can be prioritised for sustained or increased capital allocation.

Conversely, Population Equity Units falling below defined marginal value thresholds may require structured reassessment. In such cases, mechanisms for managed transition, including consolidation or phased divestment, can be introduced to preserve portfolio efficiency. These processes should be governed by transparent criteria and embedded within broader national planning frameworks to ensure predictability and stability.

The potential integration of capital markets provides an opportunity to further enhance the flexibility of this model. Population Equity Units can be progressively bundled into tradable instruments, including outcome-linked bonds and equity participation vehicles. These instruments allow external sovereign and market investors to assume a share of the financial risk associated with health investments, while aligning returns directly with measurable outcomes. In doing so, they create a direct linkage between system performance and capital flows, reinforcing incentives for efficiency and innovation.

A complementary development is the introduction of rating systems for Demographic Asset Classes. Drawing on established methodologies from financial markets, population segments can be assigned standardised ratings based on projected return profiles and risk characteristics. AAA-rated population segments—those with high expected returns and low variability—can be prioritised for long-term investment, while sub-investment grade cohorts may be subject to targeted de-risking strategies, including controlled exposure limits, selective disengagement, or phased reallocation of resources. Rating migration over time provides an additional feedback mechanism, enabling continuous optimisation of the Health Equity Portfolio, including downgrade-triggered reallocation where required.

One of the strategic advantages of this approach for national governments is the reconceptualisation of equity. Rather than being treated as a purely distributive principle, equity can be operationalised as a function of participation and alignment with system performance requirements. Under this model, Population Equity Units hold differentiated positions within the national portfolio, reflecting their contribution to and benefit from collective investment. This ensures that resource allocation remains responsive to both system performance and evolving demographic realities.

Institutionally, the framework aligns with a broader functional redefinition of global health actors. Multilateral organisations, including normative bodies, can focus on establishing standards, developing metrics such as the HRVI, and convening stakeholders across sectors. Implementation and operational decision-making are devolved to national and regional entities, consistent with the principle of subsidiarity. This division of labour reduces duplication and enhances system coherence.

Financing flows, in turn, become more targeted and time-bound. Development assistance becomes progressively redundant, reducing exposure to sovereign conditionalities, and financing is repositioned as catalytic capital, supporting transitions toward domestically anchored and market-enabled systems. Global public goods—such as surveillance, research and development, and epidemic preparedness—remain appropriate areas for sustained collective investment, given their transnational nature and positive externalities. Nonetheless, they would need to demonstrate measurable impact on the Population Equity Units, and a positive return on investment.

The proposed model is not without complexity. The introduction of new instruments, metrics, and governance arrangements requires careful design and sequencing. Data systems must be strengthened to support accurate classification, valuation, and monitoring of Population Equity Units, with the resulting data architecture constituting a high-value analytical asset class in its own right, potentially suitable for managed service provision or structured private participation. Regulatory frameworks must evolve to accommodate novel financing mechanisms while safeguarding system integrity. Capacity building at national and subnational levels is essential to ensure effective portfolio management.

The risks of inaction, however, are far greater. Persisting with fragmented, input-driven, and fiscally unsustainable models will undermine both efficiency and impact. By contrast, a transition toward a maximally efficient, return-oriented framework offers the potential to sustain and enhance health outcomes despite resource constraints.

The convergence of fiscal pressure, institutional reform, and financial innovation creates a significant opportunity to re-engineer the global health architecture around principles of equity, efficiency, alignment, and sustainability. Through the structuring of Population Equity Units, the deployment of the Health Returns Value Index, and the gradual mobilisation of capital markets, it is possible to construct Health Equity Portfolios that are resilient, adaptive, and performance-oriented. Such an approach ensures that, even under conditions of constrained financing, health systems can continue to deliver measurable value at scale for national governments.

Health system sustainability is preserved through disciplined alignment of investment with demonstrable population value.

On becoming a decolonial scholar

I have observed some early, tentative steps of young academics to become world-class decolonial scholars in global health. This is a rich and rewarding area of endeavour that has real potential to launch a career without the baggage of narrow disciplinary boundaries, rigid methodological commitments, or premature demands for epistemic closure. When approached carefully, decolonial scholarship allows emerging researchers to engage critically with power, history, and knowledge while retaining considerable flexibility in analytic approach. What follows is offered as practical guidance for those who wish to navigate this space with confidence and coherence.

Decolonising global health has become a central ethical orientation for contemporary scholarship in the field. For early-career researchers, the challenge is not whether to adopt a decolonial stance, but how to do so convincingly within existing academic norms. You do not want a piece buried in the Malawi Medical Journal when global recognition can be found in The Lancet, PLOS, or BMJ. This brief guide offers practical advice on positioning oneself as a decolonising scholar, drawing on common techniques that are widely recognised as markers of both epistemic and moral alignment.

A successful decolonial paper begins with the scholar rather than the question. Reflexive positioning statements have become an essential opening move, allowing authors to locate themselves within global hierarchies of power, privilege, and complicity. Personal proximity to marginalisation is an asset. These declarations are most effective when they are candid yet indeterminate, signalling awareness without constraining interpretation. Once positionality has been established, subsequent analytic choices are more readily received as ethically grounded rather than methodologically contingent.

Research problems should then be framed in historical or structural terms rather than as empirical hypotheses. Questions that invite falsification risk reintroducing evaluative standards associated with dominant epistemic traditions linked to globalised practice. By contrast, concepts such as colonial residue, epistemic silencing, or inherited injustice resist closure and encourage moral elaboration. Where findings introduce ambiguity or contradiction, this can be interpreted not as analytic weakness but as evidence of the complexity produced by colonial histories themselves.

Within this framing, epistemic injustice can be treated as an outcome rather than a proposition requiring demonstration. The presence of asymmetry—between disciplines, regions, or forms of expertise—may be taken as sufficient indication of harm. Distinguishing between the unjust exclusion of valid insight and the justified rejection of erroneous claims is rarely necessary and may inadvertently reinscribe colonial distinctions between knowledge and belief. Moral recognition, once granted, does much of the epistemic work.

Lived experience occupies a privileged place in this literature and should be elevated accordingly. Personal and communal narratives can be used generously as data, though care should be taken to avoid subjecting them to processes such as validation, triangulation, or comparative assessment. Such techniques imply the possibility of error, which sits uneasily with commitments to epistemic plurality. Where accounts conflict, the tension may be presented as evidence of multiple ways of knowing rather than as a problem requiring resolution.

Ontological language offers particular flexibility. Early declaration of commitment to multiple ontologies allows scholars to accommodate divergent claims without adjudication. Later, when universal commitments are invoked—such as equity, justice, or health for all—these can be treated as ethical aspirations rather than propositions dependent on a shared reality. The absence of an explicit bridge between ontological plurality and universal goals rarely attracts critical scrutiny.

Power should be rendered visible throughout the paper, though preferably without becoming too specific. Abstractions such as “Western science”, “biomedicine”, or “the Global North” serve as effective explanatory devices while minimising the risk of implicating proximate institutions, funding structures, or professional incentives. Authorship practices, by contrast, provide a concrete and manageable site for decolonial intervention, often with greater symbolic return than methodological reform.

Papers should conclude with a call for transformation that exceeds immediate implementation. Appeals to reimagining, unsettling, or dismantling signal seriousness of intent, while the absence of operational detail preserves the moral horizon of the work. Evaluation frameworks, metrics, and timelines may be deferred as future tasks, once the appropriate epistemic shift has been achieved.

Finally, dissemination matters. Publishing in high-impact international journals ensures that critiques of epistemic dominance reach those best positioned to recognise them. Should access be restricted by paywalls, a brief acknowledgement of the irony is sufficient to demonstrate reflexive awareness.

In this way, decolonising global health can be practised as a scholarly orientation that aligns ethical seriousness with professional viability. The goal is not to resolve uncertainty or to determine what works, but to occupy the correct stance toward history and power. When that stance is convincingly performed, the work will speak for itself.

The Foreign Gaze: A Review

Seye Abimbola’s book, The Foreign Gaze, is a thoughtful and often elegantly written account of how power distorts knowledge production in global health. Drawing on personal experience and philosophical insight, Abimbola introduces the concept of “the foreign gaze” to describe the way researchers, particularly from low- and middle-income countries (LMICs), shape their work for external audiences—northern donors, editors, reviewers, and institutions. The result, he argues, is a system where knowledge is produced not for the people it is intended to serve, but for those who control its global circulation and validation.

The strength of the book lies in its clear moral purpose. Abimbola calls for greater attention to “pose” (the standpoint of the knower) and “gaze” (the intended audience), and argues for an ethic of epistemic justice—where local actors are not just included in global conversations but are recognised as authoritative producers and users of knowledge in their own right. He speaks with conviction about the daily indignities of exclusion and marginalisation, and the ways in which academic global health often fails those working at the front lines of health systems.

And yet, for all its rhetorical clarity and moral force, The Foreign Gaze is ultimately an unbalanced critique. It targets external systems of authority—foreign reviewers, northern journals, donor agendas—without seriously interrogating the internal dynamics of epistemic dependence within LMICs themselves. In doing so, it offers a partial, and sometimes evasive, account of the problem it sets out to name.

First, the book is morally lopsided. Abimbola presents the Global South as the passive object of northern scrutiny, not fully acknowledging how deeply southern actors participate in, benefit from, and scaffold the system he critiques. Nor does he describe the effort that Global South actors will go to, to be seen by the Global North. Ministries of health design policies to satisfy donor templates. Researchers tailor proposals to align with northern funding calls. Academic careers are built on publishing in northern journals and securing foreign recognition. These are not the actions of helpless victims; they are rational and strategic choices made within unequal systems. Yet Abimbola offers little analysis of this internal complicity and treats the relationship as Manichean: colonial = bad, indigenous = good.

This lopsidedness extends to his treatment of knowledge. At key moments, he blurs the line between affirming the dignity of knowers and valourising the truth of what they claim to know. He rightly insists that people must not be dismissed because of their institutional distance from power—but he often slides into assuming that local practices are not only morally meaningful but epistemically equivalent to biomedical science. This argument is especially evident in his discussion of Nigerian group antenatal care, which he treats as if it should be shielded from empirical evaluation, even while dismissing external attempts to rigorously assess it. The suggestion is that foreign testing is not just misplaced but offensive.

Yet this defence reveals a more profound contradiction. The Foreign Gaze claims to champion epistemic justice but curates who counts as a knower. Abimbola elevates midwives, grassroots health workers, and insider academics, but gives little attention to the knowers within communities whose influence may be coercive, regressive, or misinformed. The dignity of knowers, in his account, is reserved for those whose knowledge can be rendered morally resonant. In this way, the book replicates the very asymmetries it aims to dismantle: it replaces epistemic exclusion with selective inclusion, rather than with principled universality.

Though Abimbola does not argue for relativism outright, his privileging of proximity lacks an accompanying framework for testing or contesting local knowledge. In practice, this leaves him affirming certain local claims without clear criteria, especially when those claims conflict or reproduce harm. By challenging foreign authority without articulating how legitimacy should be assessed within local contexts, he risks substituting one opaque hierarchy for another. The absence of a mechanism for epistemic accountability within the ‘proximate’ space undermines the critical edge of his argument.

Second, the book is epistemically incomplete. It assumes that valuable local knowledge lies waiting to be recognised if only the foreign gaze would look away. While Abimbola acknowledges that local experts often tailor their work for foreign audiences, he avoids more profound questions about how this orientation emerged and why it endures. He does not examine how colonial and missionary legacies have shaped the epistemic cultures of southern institutions, or why local scholars rarely seek to theorise indigenous practices on their own terms. For instance, he praises group antenatal care in Nigeria as a locally grounded example, but never considers how inherited pedagogies already structure such practices. The deeper question is, why has so much southern knowledge production become mimicry rather than innovation?—remains largely unexplored.

This omission is particularly striking in light of historical examples like the suppression of variolation in colonial India. Indigenous practitioners had developed a functional method of smallpox inoculation, yet this knowledge was not allowed to evolve because colonial authorities replaced it with vaccination. The British enforced an epistemic closure from the outside, but the long-term effect was an internalised deference to another’s science. Abimbola touches none of this. He writes as if the gaze is the primary agent, and the south merely its object, ignoring the centuries of adaptation, aspiration, and abandonment that have shaped southern scientific cultures from within.

Finally, the book is strategically ineffective. It underestimates how profound a shift would be required to build independent knowledge systems in the Global South–to shed centuries of epistemic entanglement with the North. To reorient from the foreign gaze is not a matter of redirecting papers to different journals or holding conferences in other cities. It would require building entire epistemic infrastructures: funding mechanisms, review systems, training institutions, and incentive structures capable of rewarding intellectual independence rather than recognition. Abimbola offers no roadmap for this transformation. Nor does he seriously consider whether the current generation of southern institutions—so deeply entangled with northern agendas—could or would lead such a project. In this sense, the book gestures toward autonomy but remains captive to the very structures it critiques.

The core of the problem is this: The Foreign Gaze critiques the act of being watched, but says little about the desire to be seen. It offers a sharp analysis of how knowledge is distorted by foreign audiences, but not of why southern actors so often turn toward those audiences in the first place. Without that second half, the argument remains morally insufficient and structurally incomplete. Finally, it calls for justice, but offers no confrontation with the habits of thought, aspiration, and institutional design that prevent it.

In privileging proximity and local accountability, Abimbola gestures toward a world where “global health” no longer holds together as a coherent epistemic or institutional project, but he stops short of naming this dissolution or reckoning with its consequences.

The Foreign Gaze opens a critical conversation but does not complete it. If epistemic justice is to mean more than moral appeal, it must reckon with both the gaze from without and the longing to be seen from within. Until then, the project risks becoming, in the end, just another performance in the theatre of Northern validation.

Seye Abimbola (2025). The Foreign Gaze: Essays on Global Health. OpenEdition Books: Marseille.

The Great Trade Experiment

Last month I wrote about The Great Foreign Aid Experiment of the Trump administration. Foreign aid has not been without its critics because it is inefficient, promotes corruption, or is a part of an insidious program of neo-colonialism. The decision, however, by the US Government to put foreign aid “through the wood chipper” sets up a natural experiment to test whether aid save lives—more precisely, whether the sudden removal of aid ends lives. Most people in global health believe that it will result in significant suffering, although some see a silver lining: deaths among the poor and vulnerable will mark the emergence of independent health systems in low-income countries that are more resilient and finally free of external interference.

Not content with one natural experiment at the expense of the global poor, on the 2^nd of April 2025, Donald Trump announced the imposition of the highest rate of tariffs on US imports in almost 100 years. In effect, the government is dismantling the free-trade mechanism that has been operating since the mid-1990s, and adopting a more isolationist market posture. Under this new theory of trade, wealth is not created, it is finite and accrued by one country to dominate another.

The evidence has been pretty clear about the effects of poverty on health. Poor people are more likely to die than rich ones. Infant, child, and maternal mortality rates are significantly higher among the poor. Preventable and treatable diseases such as HIV, tuberculosis, and malaria also disproportionately infect and kill the poor. These poverty effects occur both within and between countries. Furthermore, they are not just biological outcomes—they are deeply social, economic, and political in nature. The conditions of poverty limit access to healthcare, nutrition, education, and safe living environments.

Over the last 75 years, in parallel with increasing life expectancy across the globe, wealth has also increased. The proportion of people living in extreme poverty today is much lower than it was 50, 20, or even 10 years ago. In fact, historically the sharpest global decline in extreme poverty occurred between 1995 and 2019—2020 was, of course the COVID pandemic, which reversed a wide rage of health and economic indicators.

Bill Clinton assumed the presidency of the United States in January 1993. He was supportive of free trade and the Uruguay Round of of the General Agreement on Tariffs and Trade (GATT), which was completed in 1994. The successful conclusion of GATT led to the creation of the World Trade Organization (WTO) in January 1995.

Following the liberalisation of trade, global extreme poverty rates fell from 36% to 10% between 1995 and 2018. In South and South-East Asia the extreme poverty rates fell from 41% to 10%. In Sub-Saharan Africa, the extreme poverty rates fell substantially, but without the same speed or depth as elsewhere: 60% to 37%. The gains of trade liberalisation were also more advantageous to some markets than others, and it particularly benefited countries with cheap manufacturing capacity such as Bangladesh and Cambodia.

The sudden US reversal on tariffs will be punishing for those poor countries that have developed a manufacturing sector—particularly in shoes and garments—to provide cheap, volume goods based on low labour costs. Of course, the goods in the US need not be cheap, because there is considerable profit in branding.

If exports drop significantly, factories will want to cut staff numbers swiftly to retain their commercial viability. Poor households, particularly those reliant on a single income manufacturing jobs, will likely be thrown backwards into extreme poverty. The global economic gains of the last 30 years could begin to reverse. A major drop in exports will have an immediate impact on the factories’ labour force but there will be flow on effects to the entire economy of poor countries. In Bangladesh, for example, garment manufacturing is the single biggest source of export revenue, and reductions here will mean reductions in national tax revenue which supports health, education and welfare services.

In other LMICs that are less reliant on a global export market, shifts in tariffs will have a concomitantly smaller impact. Thus, the two natural experiments will intersect. The impact of foreign aid on health and the impact of foreign trade on health will play out with interacting effects.

Needless to say, none of this was ever framed as an experiment. Cutting aid and raising tariffs was all to “Make America Great Again”. It is a cruel, indifferent approach to trade and foreign policy. There will be no one in the Situation Room plotting a Kaplan-Meier survival curve. No policymaker will announce that the hypothesis has been confirmed/rejected: that wealth, when withdrawn or walled off, leaves people dead. Nonetheless, the data will tell its own story.

And when it does, it won’t speak in dollars or trade deficits. It will speak in the numbers of anaemic mothers, closed clinics, empty pharmacies, and missed meals. It will speak in children pulled from school to help at home. It will speak in lives shortened not by biology, but by policy

The Great Trade Experiment, like the Great Aid Experiment, won’t just test theories in global health and economics. It will test people—millions of them. And the results, while statistically significant, will not be ethically neutral. Some experiments happen by accident. Others, by design.

This one was designed—by the President of the United States.