Rebuilding Trust in Global Health Governance

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Recent health crises such as the Ebola outbreak of 2013 and the COVID-19 pandemic of 2020 have worsened the lack of trust that is crippling the global health governance. The international community’s inability to address these failings are such that UN Secretary-General António Guterres has spoken of a “global trust deficit order.”  This policy brief analyzes the reasons for the pervasive lack of trust in global health governance and proposes recommendations for Germany to lead efforts to rebuild trust among stakeholders. By leveraging its position, Germany has the potential to bridge divides and foster collaborative global health responses 

When Ebola broke out in 2013, global health institutions reacted far too slowly. Their delayed response hampered containment efforts, which led to widespread transmission and loss of life. Similarly, during COVID-19, nation-states retreated to nationalistic measures instead of engaging in multilateral cooperation: Borders were closed, countries competed fiercely for limited vaccine supplies, and a blame game ensued which further complicated international relations.  

As wealthier nations hoarded vaccines, global solidarity fractured, with countries from the Global South voicing their frustration and seeking alternatives from non-Western suppliers. Even more dramatically, governments and stakeholders did not learn from the COVID experience. Negotiations for a Pandemic Treaty, envisioned as a tool to foster trust and preparedness for future pandemics, had to be postponed due to pervasive mistrust in both the negotiation process and expectations of compliance. 

Recent events, such as the ongoing response to Mpox, a viral disease formerly known as monkey pox which is rapidly spreading in Central Africa, further underscore the fragile state of global health governance, while positive examples like the coordinated polio vaccination efforts in war-torn Gaza demonstrate that there is potential for effective multilateral action.  

The Issue of Trust  

Trust is essential to stakeholder dynamics. It enables cooperation and reduces transaction costs, thereby enhancing efficiency and effectiveness. In complex settings like global governance, trust is a multilayered effort. It requires a firm belief in another party’s good intentions, reliability, and integrity – whether the party is an individual, institution, or organization. This is of particular importance regarding global health issues because stakeholders need to believe that the commonly agreed course of action is more efficient for them than relying on national responses. In the global health governance context, trust therefore relates to the confidence in the partner to pursue and promote the common good health. 

The global health landscape is further complicated by extreme challenges in regions where health crises are most likely to emerge. Epidemics frequently occur in areas ravaged by civil wars, lacking basic infrastructure, or recovering from natural disasters. In some regions, low levels of education or cultural practices hinder public health efforts. These conditions not only impede immediate healthcare delivery but also foster mistrust towards international health initiatives.  

Global Health Governance 

Global health governance describes the cooperation of state and non-state actors to promote health and address global health challenges such as the need to protect people against health emergencies and diseases. As a common good, global health is a field with a large number of different stakeholders: Governments, philanthropies, international organizations, and non-profits are all involved in global health governance. This wide spectrum is useful because health crises are rarely limited to one country. At the same time, such diversity makes it difficult to develop the trust that is crucial for a sound and effective global health governance system  

A Fragmented Global Health Architecture  

The cause of much of the trust problem lies in the fragmentation of the global health governance architecture. Global health is managed by a very large and diverse set of state and non-state actors, including a multitude of diverse institutions such as international organizations, ad hoc alliances, and public-private partnerships. The situation lends itself to role duplication, competitive relationships, and siloed operations within global health multilateralism. The resulting “chaotic pluralism” undermines cohesive efforts, weakens trust among actors, and complicates global health governance. 

A reformed and empowered WHO is critical to building trust in global health governance 

Normative fragmentation further impedes trust in global health governance. The main normative fault line runs between universal and restricted multilateralism. Universal multilateralism – exemplified by UN organizations like the World Health Organization (WHO) – involves all states with equal voting rights and broad mandates and is based on reciprocity. In contrast, restricted multilateralism, such as public-private partnerships and vertical funds like GAVI, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria focuses on more limited goals. It has a smaller but more diverse set of stakeholders that includes non-state actors and is driven by donor priorities. For obvious reasons, effective coordination between universal and restricted multilateral organizations is as important as it is difficult.  

WHO Inefficiencies  

The WHO, positioned as the central coordinator in global health governance, struggles to assert its role due to a lack of binding rules and limited resources. This gap hampers its effectiveness and erodes trust in its leadership and global health governance as a whole. Although Article 19 of its constitution permits the establishment of binding regulations, the only treaty enacted has been the Framework Convention on Tobacco Control. Consequently, the WHO relies predominantly on non-binding guidelines, where it lacks enforcement mechanisms and the ability to penalize non-compliance. 

Both during the Ebola and the COVID-19 crises, the WHO declared health emergencies too late, partly due to its slow and bureaucratic processes and its limited ability to access crucial health data. The organization depends on member states to voluntarily share information and lacks the authority to conduct fact-finding missions without their consent. Least developed countries frequently do not have the infrastructure to be able to provide needed health data, while autocratic countries may refuse access as a matter of principle. China, for example, has still not opened its files on the origins of the COVID-19 pandemic. 

The fact that negotiations over the proposed Pandemic Treaty – a new international treaty to address pandemic prevention, preparedness, and response – have stalled, shows that member states are not easily willing to provide the WHO with more competences and the health governance architecture with more binding rules. While member state representatives rightly point towards the slow and inefficient processes within the WHO, it is the member states themselves that cannot agree on granting the WHO the necessary power to fulfil its mandate. Yet a reformed and empowered WHO would be critical to building trust in global health governance.  

The Decline of Multilateralism 

Structural causes further magnify the distrust engendered by the current global health governance. Geopolitical shifts and the rise of multipolarity have eroded trust in global governance. The diffusion of power creates an environment in which consensus is increasingly difficult to achieve, particularly at the United Nations. This leads to perceptions of ineffectiveness and bias within international institutions and gridlocks in addressing global challenges. The role played by the members of BRICS and the more outspoken Global South countries further complicates consensus building. Addressing these challenges requires redesigning international institutions to better reflect the multipolar world and fostering genuine representation and responsiveness to the needs of all nations.  

These structural trends are particularly evident in policy fields governing common goods like global health. Historically, an informal hierarchical order prevailed, with donor countries stemming primarily from the Global North and recipient countries from the Global South. However, recent structural shifts have empowered the Global South to more assertively demand global governance processes that minimize hierarchical structures. In a multipolar world, the Global South is less dependent on the West, as it can turn to alternative partners such as China and other emerging powers. This reduces the need to accept conditions imposed by the Global North and leads to diverging priorities and strategic interests among stakeholders that complicate the development of cohesive global health policies. 

For instance, during COVID-19, vaccine nationalism highlighted the lack of solidarity, as wealthier nations hoarded resources and undermined equitable distribution. As a result, countries from the Global South vocally criticized this approach by Western countries and turned towards non-Western vaccine producers such as China or Russia. Vaccine distribution then turned into a geopolitical contest, to the detriment of Western countries’ reputation among developing countries. 

These examples illustrate how geopolitical rivalries and a multipolar framework obstruct cooperative efforts, fostering skepticism about the ability of global governance systems to manage common goods effectively and equitably. This underscores the urgent need for reforms to establish inclusive, resilient cooperation mechanisms that can restore trust among stakeholders – in global health governance in particular but also in global governance in general. 

Germany’s Potential to Lead 

In the realm of global health governance, states have clear opportunities as well as inherent limitations. While they cannot prevent wars or natural disasters, and while it would be unreasonable to expect them to disregard their national interests during global health crises, they can play a pivotal role in strengthening international cooperation through institutions like the WHO. States can use these platforms to develop global health regulations, coordinate emergency responses, and ensure equitable access to vaccines and medical supplies. Strengthening multilateral institutions is crucial to ensuring more effective, coordinated global health responses even as states remain bound by their national obligations. 

Germany must increase its visibility in global health governance 

Germany’s Global Health Strategy emphasizes strengthening the global health architecture through enhanced multilateral cooperation. It clearly recognizes that collective action is essential to address global health challenges. Drawing lessons from COVID-19, Germany calls for a reformed, empowered WHO at the core of a robust universal multilateral system to ensure effective responses to global health risks. Simultaneously, it acknowledges the raison d’être of restricted multilateralism and organizations such as GAVI and the Global Fund.  

As a prominent actor in global health governance – structurally, politically, financially, scientifically, and economically – Germany is well positioned to take up a leading role in rebuilding trust in global health governance. It is one of the largest donor countries for development assistance and global health. In 2023, Germany’s official development assistance (ODA) amounted to $35.7 billion, which makes Germany the second largest donor in the world in absolute terms. Also in relative terms, Germany is a leading figure as it invests 0.79 percent of its gross national income on ODA. This makes Germany the fourth largest donor in relative terms and part of a selected group of only five countries who reach the target goal of 0.7 percent of GNI for ODA. In absolute terms, Germany’s ODA contribution to global health amounted to $4.391 billion, making it the second-largest donor to global health.  

Since 2015, global health has been a priority in Germany’s development policy. Berlin put global health policy on the agenda of its G7 and G20 presidencies in 2017 and 2022, which included convening health ministers for the first time in these formats. Chancellor Olaf Scholz reaffirmed this commitment in 2024 at the 25th International AIDS Conference in Munich, emphasizing it as a political and financial priority. But despite its potential, Germany falls short of the leadership needed to drive trust-building in global health. While a study among international experts highlights Germany’s strong credibility and reputation as a value-oriented donor, Germany lacks the influence to shape the global agenda.  

Recommendations 

To lead efforts in rebuilding trust, Germany must increase its visibility in global health governance. By leveraging its political will, scientific expertise, economic strength, and diplomatic credibility, it can drive reforms within the WHO, amplify the Global South’s role, and ultimately rebuild trust in global health governance processes. 

Rebuilding trust in global health governance, as Olaf Scholz pointed out, requires a broader range of actors to create a “stronger chain with even more reliable links.” The following recommendations outline the steps Germany should take to lead those efforts 

Introduce Indicators to Measure Health ­Governance Progress  

Germany’s global health strategy sets out its commitment to playing an active role in global health governance and strengthening the WHO. However, the strategy lacks focus on rebuilding trust in global health institutions and does not include an implementation plan with measurable indicators to track its success. Such indicators are crucial in terms of accountability and credibility. In its 2025 review, Germany should incorporate trust building as a key goal and introduce measurable indicators to assess its impact on global health governance. 

Reassess Federal Budget Cuts 

One way to show one’s own trust in the multilateral system is to provide sufficient funding for its institutions. As one of the largest donor countries, expectations for Germany are particularly high. However, the current federal budget draft for 2025 proposes significant budget cuts for the Federal Foreign Office (minus 12.5 percent) and the Ministry for Economic Cooperation and Development (minus 8.4 percent). These proposals have been the central topic of concern in the global health governance discourse for months, with many stakeholders actively opposing them. The mismatch between Germany’s vocal support for international cooperation and its planned budget reductions sends a troubling message to global stakeholders and undermines trust in both Germany and the multilateral system. Large-scale cuts by one of the ­primary donors could worsen existing challenges in global health governance. 

While the United States currently is the world’s largest donor, this could change if Donald Trump wins the November elections. In his first term as president, Trump reduced payments to the multilateral system and cut all funds to the WHO. Should he be elected again, Germany must be prepared to take on a bigger share. At the very minimum, Germany needs to maintain its current level of funding to credibly demand higher contributions from other countries. As the federal budget has not yet passed the Bundestag, there is still room to maneuver. To maintain Germany’s credibility as a leader for building trust in global health governance, members of the Bundestag should reassess the government’s planned budget cuts in foreign and development policy to minimize the negative impact on global governance processes. 

Fund the WHO 

Around 75 percent of the WHO budget is earmarked, reflecting states’ priorities on the organization’s work. Yet earmarked contributions limit the flexibility of the WHO to quickly respond to emerging crises. They also encourage short-term priorities over the long-term strengthening of the health system. As a result, health efforts become fragmented und uncoordinated. The high proportion of earmarked contributions also weakens trust in global health governance since they can create the impression that global health governance mainly serves the interests of powerful donors.  

To be able act more strategically and flexibly, the WHO continuously calls on its member states to provide more unconditional funding. Germany is the organization’s second largest funder but currently, only ten percent of its voluntary contributions are not earmarked. Increasing this category of funding would demonstrate to other member states Germany’s trust in the WHO as the central coordinating force of global health governance. It might also encourage imitation by other member states.  

Do More to Bring in the Global South  

To bridge the growing divide between the Global South and Global North, Germany should actively continue and expand its efforts to associate Global South nations to key forums like the G7. Chancellor Olaf Scholz’s 2023 advocacy for deeper cooperation with the Global South marks a promising start, but this approach must be further advanced, particularly in addressing global health issues. The T7 and T20, traditionally composed of engagement groups from member countries, should expand their scope to include more relevant stakeholders from the Global South. They should focus on issue-specific participation rather than limit involvement to member states. Such inclusivity would foster trust among stakeholders. It would strengthen global cooperation and trust and help overcome the gridlock in which North-South divides have previously hindered progress such as in the negotiations of the Pandemic Treaty. 

The author would like to thank Amelie Krüger for her assistance in the research and writing process.