Introduction

If global health architecture is to be transformed, what should be the ethical principle that guides it? What values should inform the design of its institutions, decisions about financing, and the way power is distributed among regions, countries, and communities? Can we talk about a truly fair architecture if its moral purpose and commitment to equity are not first defined?

In a context where structural inequalities continue to determine who has access to health care and who is left behind, how can a new architecture avoid reproducing the historical and structural imbalances it has inherited? How can it integrate an ethical understanding of health that recognizes the dignity and interdependence of all people? What mechanisms can ensure that the principles of justice, transparency, and shared responsibility are translated into institutional practice and not just aspiration?

If equity is the end goal, what should be the ethical means to achieve it? Should the new architecture explicitly take on the repair of historical inequalities as part of its mandate? How can a principle of global solidarity be articulated that does not depend on charity, but on the recognition of a common responsibility? Could the effective participation of communities—especially those historically marginalized—become a guiding principle rather than an accessory component of institutional design?

Finally, if architecture seeks to redistribute power and capacity, how should health justice be defined in operational terms? Should it be measured only by health outcomes or also by the degree of autonomy, voice, and self-determination achieved by peoples? Is it possible to imagine an ethics of architecture that recognizes cultural diversity, local knowledge, and plurality of ways of understanding well-being?

These questions seek to open a collective reflection on how a global architecture, anchored in clear ethical principles, can sustain a genuine transformation toward equity and social justice in health.

 

Reflections derived from the interviews

Failures in Global Architecture and Cooperation on Equity

1. Power asymmetries in governance: Latin America “only executes rules that others create” without participating in co-decisions or spaces for health diplomacy. Small countries have less voice in global and regional institutions.
2. Inadequate Classification by GDP: The per capita income criterion excludes countries with real needs (e.g., Argentina as upper income), despite persistent gaps in poverty and vulnerability.
3. Special Vulnerabilities Ignored: The special vulnerabilities of small island developing states (SIDS) that suffer disproportionately from climate emergencies, logistics, and the impact of distant geopolitical crises (e.g., the war in Ukraine raised the cost of living by up to 10%) are not recognized.
4. Inequality in Access to Global Public Goods: There is a gap in vaccine production capacity (concentrated in Brazil). There are persistent asymmetries in access to intellectual property (IP), medicines, and interventions. IP is assumed to be individual work when it is a collectively constructed good.
5. Fragmentation and Welfare: The fragmentation of windows and vertical programs favors countries with greater formulation capacity. These programs often work well while they last and then disappear without leaving installed capacity or knowledge transfer. Funding brings with it the ideology and agenda of the funder, reducing national autonomy.

2. Identified Proposals

The proposals seek to transform the governance, financing, and operation of health cooperation, prioritizing equity and a territorial approach.

Governance and Institutional Design for Equity

1. Explicit Equity Mandate: The architecture must be based on the premise of “reducing the inequality gap and promoting health justice.”
2. Principle of Subsidiarity and Decentralization: Apply subsidiarity to ensure that decisions are made at the level closest to vulnerable populations. Strengthen capacities from and for the territory and empower communities (effective decentralization).
3. Global Commons Coordinating Council: Create a new multilateral governance structure that serves as a “protective umbrella” to minimize the impact of geopolitics on access to public goods (medicines, vaccines, technologies).
4. Equitable Representation and Inclusion of Voices: Ensure that smaller countries have a voice proportional to their needs. Form working groups that include the community, patients, social organizations, academia, and community-based NGOs, not just experts and governments.

Financing and Eligibility Criteria

1. Review of Graduation Criteria: It is crucial to review the criteria that label countries as “high-income.” The new criteria should be based on actual need, not just per capita GDP, and incorporate climate vulnerabilities, size, economic dependence, and internal gaps.
2. Progressive Financing: Resource distribution formulas should direct more resources to countries and regions with greater need.
3. Co-financing Mechanisms (Matching Funds): Implement mechanisms that allow countries with political will to co-finance in order to access global funds, overcoming income classification.
4. Reform of IFIs: Address IMF and World Bank conditionalities that often result in public sector cuts and weaken health response capacity.

Access to Technologies and Cooperation

1. Genuine Technology Transfer: Expand vaccine and drug production capacity beyond Brazil. Effective technology transfer is achieved when there are clear incentives, such as a guaranteed market.
2. Collective Purchasing Mechanisms: Strengthen and optimize revolving funds, as they particularly benefit small countries with less bargaining power. A regional collective purchasing mechanism (e.g., OECS) is proposed.
3. Intellectual Property (IP) Reform: Provide guidance on niches and opportunities for greater access to medicines. Recognize molecules as a collectively constructed good.
4. South-South Cooperation: Encourage exchange between countries with similar capacities, as an alternative to North-South cooperation, to strengthen capacities in weaker countries.

Differentiated and Territorial Approaches

1. Primary Care and Local Approach: Prioritize strengthening the first level of care, as strong primary care resolves 80% of health problems. Health should be viewed as local, personal, family, and community-based.
2. Interculturality in Health: Propose integrating ancestral and traditional medicine into the formal system, recognizing its value and the evidence that it saved thousands of lives during COVID.
3. Strategies for Border Areas: Establish binational framework agreements to formalize cross-border care and harmonize requirements (e.g., shared medical records, recognition of professionals).
4. Free Movement of Professionals: Create the legal and institutional space for the free movement of health professionals across different jurisdictions, overcoming shortages in the region.

3. Areas of Convergence and Tension

Convergences

There is universal consensus on several critical points:

1. Priority on Structural Equity: Unanimous agreement that the current model does not adequately address inequities and that inequality is the fundamental problem in Latin America and the Caribbean.
2. Failure of Income Criteria: Convergence that eligibility criteria based solely on GDP are insufficient and should be revised.
3. Role of Joint Purchasing: Agreement that joint purchasing is a key tool for equity, benefiting small countries in particular.
4. Territorial Approach and PHC: Agreement that health is local and that strengthening Primary Health Care (PHC) is the basis for achieving equity.
5. Vulnerabilities and Advocacy: Recognition that global crises disproportionately impact small states and the need for unified advocacy in international forums.

Tensions

1. Equity vs. Efficiency: Tension over whether prioritizing the most vulnerable populations (equity) may work against reaching a larger number of people (economic efficiency). Example of investing in neglected diseases that affect few vs. prevalent diseases that affect many.
2. Universalism vs. Targeting: Debate between implementing universal coverage policies or focusing on programs highly targeted at vulnerable groups, with the risk that the latter perpetuate inequality.
3. National Sovereignty vs. Regional Solidarity: Tension between national autonomy and the need for regional aid and cooperation. This is exacerbated in border areas, where stronger systems (e.g., Uruguay) serve weaker neighboring areas (e.g., Brazil).
4. Global Standards vs. Local Relevance: Tension between applying rigid international protocols or adapting the system to local realities and the capacity of the territory.
5. Intellectual Property vs. Access: The debate between protecting incentives for pharmaceutical innovation and ensuring equitable access to vital medicines, recognizing that molecules are a collectively constructed good.
6. Community Participation vs. Decision-Making Efficiency: The need to include multiple voices and co-governance to ensure legitimacy can slow down decision-making.

Identified Contradictions

Despite the rhetoric of equity, there are practical contradictions:

• There is talk of equity, but there are few concrete proposals for the redistribution of resources from rich countries in the region to poor ones.
• The exclusion of Latin America from global decisions is criticized, but the region does not coordinate to speak with one voice.
• It is proposed to include vulnerable populations in governance, but there is a lack of concrete mechanisms to make this effective and not just symbolic.

4. Questions proposed for the working group

A. On the ethical principle that should guide the new architecture

1. Which ethical principle—equity, solidarity, restorative justice, self-determination, or human dignity—should constitute the moral foundation of the new global health architecture?
2. How can we translate that ethical principle into concrete decisions about power distribution, financing, and knowledge generation within the global health system?
3. How can this principle help correct historical imbalances between regions, countries, and communities without reproducing preexisting dependencies or hierarchies?

B. On the structural characteristics necessary to realize that principle

1. What institutional characteristics—for example, participatory governance, accountability mechanisms, or decentralized regional structures—are essential for equity to be not just a declarative value, but a daily practice of the global health architecture?
2. How can we ensure that the ethical and distributive decisions of the architecture are maintained over time, even in the face of political, financial, or geopolitical changes?