Spanish top health official: New global health architecture must break with ‘inherited structures’

Amid the US retreat from global health, calls have grown for others to step forward. Spain has been among the few to do so. Just a week after showcasing Spain’s role in helping the World Health Organization (WHO) evacuate the passengers from the hantavirus-hit cruise ship, prime minister Pedro Sánchez travelled to Geneva for the World Health Assembly to reaffirm the importance of multilateralism and Spain’s commitment to it.

While many traditional donors have scaled back aid, Spain has done the opposite, Sanchez said, raising its development budget by 13 per cent and allocating €315 million to global health last year. But between the gaping hole left by the US and most countries struggling to meet their populations’ health needs, redesigning the global health architecture faces considerable challenges that no country alone can solve.

Geneva Solutions spoke to Javier Padilla Bernáldez, health state secretary and second in command to Spain’s health minister, about how the country plans to help shape tomorrow’s global health.

This interview has been translated from Spanish into English and edited for clarity.

Geneva Solutions: What are Spain’s priorities for reforming the global health architecture?

Javier Padilla Bernáldez: From the very beginning, we’ve expressed, on the one hand, the genuine need to equip ourselves with a solid architecture capable of responding to existing challenges, and on the other, our commitment to trying to reorganise it. To do this, we need to establish financing mechanisms that are adequate and reflect the different balances at the global level. We must also avoid duplication and place each mandate within the organisation best placed to carry it out. We already have a live example of this with UNAids – the relocation of its functions either to the UN human rights office or to the WHO. Any redesign exercise will likely begin with certain deficits that will need to be corrected along the way.

We also need to avoid recreating major dependencies. And all of this has to happen not in a static context but alongside the hantavirus crisis two weeks ago, the new Ebola emergency and whatever may come from the worsening child mortality figures resulting from reduced development funding from some donors.

How do you avoid recreating those dependencies? Does it mean asking other countries to contribute more?

Eliminating duplication will in itself bring about a reduction on the demand side. But clearly, work needs to be done on the supply side. Spain, in recent years, has been one of the few countries that has expanded in a context of contraction. The question is: which other countries will step into that role? Countries like Brazil and South Africa have been repositioning themselves in the global health landscape with ambitious policies and with a notably long-term vision. We will have to see what leadership those countries provide.

But this step forward also needs to come with a corresponding sense of return on that political investment. We come from a global health landscape that has been very bipolar – the United States and some European countries on one side, and regions that were clearly in a recipient role on the other. That is undergoing a total and absolute transformation. So the main challenge is for the new architecture to genuinely reflect what the real balances are today, rather than carrying forward those inherited structures – including an extreme dependence on the US.

Equity has been a longstanding demand from developing nations. The extension of the PABS negotiations is a clear sign that it remains a sticking point. How should it be tackled?

I have to say I am fully satisfied with our country’s position – pushing for greater flexibility in the European Union’s stance across the PABS negotiations and the pandemic agreement negotiations. There is still a tendency to think about equity-related elements – such as technology transfer – within an outdated framework and an assumption that northern countries will transfer technology to the global south when a pandemic breaks out. But Omicron was first sequenced in South Africa. There are vaccine and pharmaceutical development capacities in Brazil that could lead to technology transfer running in the opposite direction. So I think we need more of John Rawls’s veil of ignorance – the capacity to position ourselves and propose agreements that are not, or at least not too heavily, constrained by our starting position.

That said, I think it is almost a moral imperative to reach an agreement on PABS that can actually be implemented. The Ebola outbreak will be the first public health emergency of international concern to occur after the dismantling of USAid and the global funding crisis. We’re going to start seeing a shortage of healthcare workers in the field. So we should be mobilising resources and not waiting for imported cases to appear in high-income countries, which is probably what will finally trigger resource mobilisation. And the WHO should be precisely the catalyst for that.

Spain recently joined the Global Leaders Network, a coalition chaired by South Africa, focused on elevating the health needs of women, children and adolescents. The US has made a radical policy shift, essentially banning its aid from going to women’s rights, particularly related to sexual and reproductive health. How does Spain plan to counteract that?

There is a trend running through several countries – from removing words like “diversity” or “gender” from any resolution, to concrete policies that restrict free, accessible abortion or contraception. And just as it arrived, it can leave when governments change. That said, in 2025, we approved Spain’s Global Health Strategy, and one of its central pillars is gender equity in health. Spain – especially through the Spanish Agency for International Development Cooperation – has concrete funding lines, particularly in Latin America, but not only there, specifically related to gender. But this cannot rest on a single country, and certainly not on Spain alone. So I think there is a dual action needed: on one hand, the concrete allocation of funds; on the other, a cultural battle – continuing to insist on having this issue on the agenda.

Do you see the global health reform process as an opportunity to secure gender equity as a priority in the future global health architecture?

We need to be careful not to expect the global health reform to fix all problems at once. We need to aim for a procedural reform that we can then work with going forward – because otherwise it will be dead on arrival. This means a set of rules that allows for recapitalisation, that provides sustainable models, with a very clear distribution of mandates, and then from there, identify where the key spaces for alliances are.