A review of global health architecture reform efforts—navigating between reform and fragmentation

A multitude of initiatives addressing global health architecture reform have materialized following the rapid changes in official development assistance in 2025. There is widespread agreement that an overhaul is vital alongside a realignment towards country-led priority-setting. However, the myriad initiatives may result in replicating the failed architecture of the past through again reinforcing donor-led agendas, duplication of efforts, top-down approaches and fragmentation. In response to this, we aimed to map 11 key initiatives of global health architecture reform through predefined categories, addressing domains, mechanisms, thematic areas, governance and financing. The 11 initiatives included are: Accra Reset; Africa CDC Health Security and Sovereignty Initiative; European Donor Alignment; Gavi Leap; Health Works Leaders Coalition; HEAR CSO Consortium; Lusaka Agenda; Sevilla Platform of Action; US Bilateral Health Agreements; WHO Global Health Architecture Reform Process; Wellcome Trust Convening Dialogues. Applying a comparative analysis, we identified key areas of consensus, duplication, fragmentation, gaps and emerging themes. To help further understanding, we share details of the current experience in Uganda with a focus on financing as a case-study. We find that most initiatives target shaping alignment/efficiency or financing/funding as primary domains, while capacity building is largely missing. This creates a disconnect between reform ambitions and capacity to deliver. While governance is intrinsic to any architecture reform, we found diverse approaches leading to unclear governance and accountability overall. Further, while financing and funding underpins any capacity for realistic reform and progress, there is a lack of concrete detail on how increased fiscal space and such capacity will be created nor a strong acknowledgment of the need for increased financing amid ongoing cuts. We conclude by highlighting critical outstanding questions to further guide the reform process, including design, governance, mandates, financing, milestones, financing, and accountability.