Introduction
Since the 1960s, Third World Approaches to International Law (TWAIL) scholarsFootnote 1 have argued that decolonization requires more than formal sovereignty; it demands equal participation by low- and middle-income countries (LMICs), particularly post-colonial states, in meaningfully shaping the rules of international order. The global health governance system, however, was largely constructed within a post-World War II order and, thus, reproduced rather than dismantled imperial hierarchies. Power and agenda-setting authority remained concentrated in former colonial states, Western hegemonic powers, and newly created international institutions that entrenched asymmetrical decision making. Over the past eight decades, global health governance has thus been disproportionately shaped by Global North actors, limiting the ability of many states to exercise meaningful agency and influence. The result has been a persistent erosion of principles of equitable global health and international law, including a core principle of participation, rooted not in the absence of legal recognition but in the centralized allocation of authority within global health institutions and organizations.Footnote 2
The emergence of global health security as a central organizing framework was reinforced by subsequent global health crises, including the West African Ebola outbreak,Footnote 3 the emergence of Middle East Respiratory Syndrome (MERS), and the specter of “Disease X.” These crises reinforced existing governance templates by accelerating securitized approaches to preparedness, surveillance, and response. In the aftermath of these events, leadership roles and decision-making authority became further concentrated within a limited set of institutions and states positioned to mobilize resources, expertise, and legal influence. Within this configuration, the United States assumed an increasingly prominent role in shaping the norms, priorities, and modalities through which global health security would be pursued.
A History of Leadership: The United States as an Architect of Global Health Security
It is impossible to overstate the United States’ presence and leadership in shaping multilateral policy forums for global health security. As a founding member of the United Nations (UN) Footnote 4 and a leading designer of the global health architecture, including the World Health Organization (WHO)Footnote 5 and its regional precursor, the Pan American Health Organization (PAHO),Footnote 6 U.S. agencies and political leaders used those fora to drive multilateral engagement on defining public health issues from smallpox eradication to the development of International Health Regulations. The United States expanded this engagement to the United Nations General Assembly, Group of 7 (G7), Group of 20 (G20), and other negotiating blocs to advance its agenda of disease elimination and health systems strengthening.Footnote 7
Beyond its diplomatic engagement, the country’s technical expertise and leadership gained it access to African Union (AU) and Association of Southeast Asian Nations (ASEAN) conversations regarding global health, including securing a commitment from African government leaders ending AIDS on the continent Footnote 8 and supporting the establishment of the ASEAN Center for Public Health Emergencies and Emerging Diseases.Footnote 9 Through a web of geopolitical health security collaborations operating in bilateral, regional,Footnote 10 and international settings, the United States consolidated a position of influence that shaped which priorities were of national and global importance,Footnote 11 how resources were to be mobilized, and which practices and strategies were implemented across the global health security landscape.
However, the United States’ leadership was far from perfect; fissures fractured into fault lines during the COVID-19 pandemic. COVAX—a partnership between the Gates Foundation, Gavi, the WHO, and others—fell short in facilitating vaccine access worldwide, having only reached 16 percent of its goal by the end of September 2021.Footnote 12 Faced with these challenges, African countries found themselves unable to purchase vaccines due to allocation practices of high-income countries.Footnote 13 From an international law perspective, these failures exposed the limits of a governance model in which authority was centralized but compliance, capacity, and legitimacy were unevenly distributed.
Ongoing political shifts in the United States that underpinned the country’s growing public health contraction left partners throughout the sector wary of the United States’ long-term reliability.Footnote 14 The sector’s fragility in the face of political headwinds has been underscored by recent steps to build on the United States’ roadmap for “self-reliance” and wind down its investments in international initiatives,Footnote 15 by dismantling the United States Agency for International Development (USAID) and outlining a more explicitly geopolitical and transactional approach to global partnership in the release of its America First Global Health Strategy. Footnote 16 Other countries facing similar political shifts, including France, Germany, and the United Kingdom, also adopted similar policies emphasizing efficiency and domestic responsibility of global health initiatives.Footnote 17
Multipolarity Takes Hold: Post-COVID Realignments and New Diplomatic Centers
In de-colonial legal theory, decentralization is not just about multiplying diplomatic venues but redistributing normative authority.Footnote 18 Well before America’s retrenchment, LMICs had begun building their own technical, financial, and political influence, positioning and empowering themselves for the poly-crisis era. Footnote 19 For example, as calls for multilateral reform and an equitable, fit-for-purpose modelFootnote 20 reached a fever pitch, Saudi Arabia leveraged the ministerial health track of its G20 presidency to elevate health and position itself as a convener of high-income and emerging economies.Footnote 21 Chile called for a pandemic treaty in 2020 and others, including the European Union, echoed their rallying cry, leading WHO member states to establish an Intergovernmental Negotiating Body (INB) to draft the first pandemic treaty in history that was ultimately adopted in May 2025. Footnote 22 Meanwhile, a United Nations resolution shepherded by South Africa,Footnote 23 to hold a historic High-Level Meeting on Pandemic Prevention, Preparedness, and Response (PPPR)Footnote 24 and establish pandemics as a UN General Assembly priority was adopted by ninety-seven member states. Footnote 25 The United States was notably absent from this historic resolutionFootnote 26 and faced powerful negotiating blocs, including the Group of Equity,Footnote 27 during concurrent pandemic treaty negotiations. These negotiations illustrate how decentralization functions as decolonization in practice: by contesting who authors global health norms, how international policy questions such as access to countermeasures and benefit-sharing are framed, and which institutional forums possess the authority to define preparedness obligations. That these debates increasingly unfold outside traditional Western-dominated settings suggests a redistribution of legal influence, even where consensus remains incomplete.Footnote 28 This transition toward a more pluralistic configuration of power signals a change in the articulation of standards and strategies beyond historical authorities.
The launch of the Lusaka Agenda by a coalition of governments and global health institutions in 2023 and recently recognized by the G20 during South Africa’s 2025 presidency serves as a prime example.Footnote 29 The agenda commits countries to stronger coordination between domestic and international investments, de-siloing of health priorities, and greater national alignment of global health financing with country plans.Footnote 30 The agenda offers a roadmap for better coordination between major global health initiatives such as Gavi the Vaccine Alliance or the Global Fund to Fight AIDS, Tuberculosis, and Malaria and government authorities or local actors.Footnote 31 It also builds on and implicitly critiques earlier regional commitments such as the 2001 Abuja Declaration, whose financial commitments urged African governments to allocate at least 15 percent of national budgets to health, a target that remains unmet more than two decades later.Footnote 32 This initiative, and others like it, signals a recalibration of authority in global health diplomacy.
Footsteps to Freedom: Emerging Multilateral Mechanisms for Global Health Security
The significance of these developments can reconfigure pathways to how international law is operationalized. The proliferation of regional initiatives that have continued since 2020 demonstrates the emergence and endurance of a new global health pluralism. Countries from China to the Caribbean have accelerated their biomedical industry ambitions, drawing lessons from the vaccine inequity that stunted our global pandemic response,Footnote 33 by establishing mRNA hubs supported by the WHO to boost their own supply chains for future medical innovations.Footnote 34 The African Union launched a vaccine initiative designed to provide at least 60 percent of the continent’s needs.Footnote 35 PAHO’s Latin America program for the production of essential medicines and technologies,Footnote 36 illustrates similar ambitions to expand shared drug development and regulatory capacity. These comprehensive efforts—from research and sourcing of raw materials to development of medical countermeasures and their delivery—likely reflect lessons learned from shared liability to the transfer of technical knowhow for vaccines.Footnote 37 That said, challenges remain, including structural barriersFootnote 38 that stall momentum and sustainability such as limited workforce capacity or low market demand in the absence of an emergency.
Furthermore, decentralization does not necessarily eliminate hierarchy or inequity. It will be important to monitor whether these emerging dynamics can meet accelerating changes to global health diplomacy, in response to nationalist policies. For example, the proposed Pathogen Access and Benefit-Sharing (PABS) system—advanced largely at the insistence of LMICs to address structural inequities—now risks dilution, as negotiations permit continued reliance on bilateral arrangements that potentially undercut hard-won international agreements. Footnote 39 The durability and impact of decentralization, as tested recently in Kenya, will be shaped in part by whether domestic legal institutions can withstand a new operational framework promoted by the United States—or other countries following suit—that favor direct country negotiations over multilateral global health security engagements.Footnote 40
Diplomatic forums likely will remain an important vehicle for identifying and cementing new ways of working that facilitate tangible multipolar solutions. Notably, India, Brazil, and South Africa have held successive G20 presidencies, with each of them advancing regional manufacturing and universal health commitments.Footnote 41 Given the recent addition of the African Union to this forum, it is reasonable to expect this to continue. Regardless, a precedent for agenda-setting by LMICs in global health security has been firmly set and exemplified through BRICS summits, where cooperative initiatives in research and development among member states, in addition to regulatory alignment, have grown since the pandemic.Footnote 42 Such shifts in global health diplomacy follow a growing trend beyond the sector. By insisting on an LMIC lens and leadership, climate policy conferences have challenged prevailing norms and outcomes.Footnote 43 These developments align with a broader tendency in international governance to reallocate institutional authority and legitimacy outside of traditional Western centers.Footnote 44
Conclusion
The combined pressures of COVID-19 and demands for multilateral reform with United States and other G7 country retrenchment have not only shifted the contours of health diplomacy, they also have shifted its governing logic. Consequently, the contraction of United States’ and other countries’ engagement in global health security has revealed both the vulnerabilities and opportunities inherent in this transition: vulnerabilities where reliance on external stewardship once ensured resources and coordination, and opportunities where new centers of leadership, political determination, and financing have begun to take shape. Although nascent, this realignment has followed trends in national governments and regional alliances, marking a shift in global health security’s traditional power dynamics toward decentralization. Decentralization does not guarantee decolonization. But where it redistributes normative authority, pluralizes the sources of legal legitimacy, and aligns financing with locally articulated priorities, it can operate as a decolonial intervention in global health law. The task ahead is to discipline decentralization through safeguards that preserve coherence, accountability, and equity within an increasingly plural international legal order.
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