The global health landscape is at a critical juncture, with the World Health Assembly (WHA) presenting a pivotal moment for action. The recent withdrawal of the United States from the World Health Organization (WHO) and the emergence of bilateral health deals under the America First Global Health Strategy have created a funding gap and a shift in power dynamics. This article delves into the urgent need for reform and the crucial role of middle powers in driving change. It emphasizes the importance of genuine partnership between Western middle powers and the Global South, as advocated by Canadian Prime Minister Mark Carney and Finnish President Alexander Stubb. Carney's concept of 'variable geometry' suggests building coalitions for specific issues, allowing for a more flexible and responsive approach to global health challenges. This approach is particularly relevant in addressing pandemic preparedness, antimicrobial resistance, digital health governance, and climate-health linkages. Stubb's argument highlights the Global South's decisive role in shaping the next world order, challenging the West to move beyond monologue and engage in genuine power-sharing negotiations. The article underscores the need for concrete structural reform in global multilateral institutions, including new permanent representation for Asia, Africa, and Latin America. It emphasizes the importance of middle powers driving the WHO reform process, ensuring genuine political ownership, clear timelines, and accountability benchmarks. The digital health governance gap and the risk of bilateralism are also addressed, calling for binding intent and strengthened legal and institutional frameworks to protect countries from asymmetric bilateral health compacts. The article concludes by emphasizing the urgency of action, stating that middle powers have the convening power, institutional credibility, and political relationships to prevent the gravitational pull of bilateralism. Inaction, it argues, is a dangerous choice that could lead to the erosion of multilateral health governance.
