An architecture that needs no dominant donor demands collective action in institutional form

Agreement: I Agree Body: Dear Editor Tang and colleagues’ argument is timely. China will not rescue the donor-dependent global health order, nor should it be expected to. What we should aim for is indeed “an architecture that needs no new dominant donor”. The editorial leaves unanswered a critical question: who finances and governs the shared capabilities the authors call for? Without an adequate answer, the vision of shared capabilities risks reproducing the donor-dependent order it seeks to transcend. The donor-dependent order reflects a material reality: the resources and capabilities to develop and deploy essential health products and services are concentrated in a small number of nations. And for far too long, we have, implicitly or explicitly, accepted it as unavoidable. Moving beyond that order towards a vision of shared capabilities therefore requires an institutional mechanism to pool resources and a collective commitment to building capability for the many, not just the privileged few. Global health initiatives such as the Global Fund and Gavi, the Vaccine Alliance, were established in the early 2000s in recognition of this need and have since contributed significantly to global public health. But times have changed. So have relations among nations. Today, the global health architecture would benefit greatly from strong, well-coordinated regional nodes so that decisions are taken at the level closest to where they matter. Regional financing mechanisms for public health R&D can give the authors’ vision a collective, institutional form. An R&D ecosystem cannot substitute for a health system, but the tools and skills it generates are integral to one. Three design choices are crucial. First, states are the most critical funders. They bear the primary responsibility for investing in solving public health threats that nations cannot solve in isolation such as climate change, antimicrobial resistance and pandemics. Inclusive governance can be safeguarded through design features that invite contributions scaled to each nation’s fiscal capacity and prevent dominance by the largest contributors and marginalisation of the smallest. Mission-aligned philanthropic and civil society organisations play an important role in steering governance towards transnational benefit rather than the interests of any single government. Second, a regional mechanism should finance the end-to-end R&D pathway, including skills development, so that it leaves durable capabilities, not just products. Few funders support training personnel required across discovery, development, manufacturing and regulation because it is costly, requires long-term commitment and, therefore, is considered “inefficient”. This is how we have legitimised concentrating the capabilities the authors value in a few countries even with the best of intentions. A pooled regional fund can draw on complementary strengths within a region, so that capability is built collectively rather than in a few centres. Third, a coalition of governments can and should do what markets cannot do: set joint policies on technology transfer and licence sharing, so that regionally funded products are developed and delivered as public goods, not private commodities. Africa has set out this vision through the New Public Health Order and the Accra Reset.¹ Latin America has shown through the PAHO Revolving Funds that regional cooperation works.² Asia remains the most fragmented region, yet it holds significant material resources and much of the research and manufacturing capacity the authors describe, in China but also in India, Korea, Thailand, Singapore and beyond. Much can be done if Asia steps up, and the time to act is now. If our destination is a global health architecture that does not rely on dominant donors, the task ahead is to build shared institutions that pool resources for common goals. 1. Accra Reset. The Accra Reset: a new blueprint for health sovereignty and shared prosperity. 2025. https://d2nhv1us8wflpq.cloudfront.net/prod/uploads/2025/10/Accra-Reset.pdf 2. Pan American Health Organization. Regional revolving funds. 2024. https://extranet.who.int/prequal/sites/default/files/document_files/day3... No competing Interests: No competing interests The following competing Interests: I am serving on the Evaluation and Selection Panel of SEA DREAM, a Thailand-based research funder, until 20 October 2026. I was Executive Director of the RIGHT Foundation, a Korea-based global health R&D funder, from September 2021 to December 2025, and Senior Advisor to the same organisation from January to June 2026. Electronic Publication Date: Sunday, October 11, 2026 - 00:31 AI use: Yes I have used AI AI use details: I have used AI strictly for improving spelling and grammar as a non-native English speaker. Highwire Comment Subject: Will China be global health’s new donor? Workflow State: Released Full Title: An architecture that needs no dominant donor demands collective action in institutional form Highwire Comment Response to: Check this box if you would like your letter to appear anonymously:: Last Name: Kim First name and middle initial: Hani Email: hani.kim@healthcollaboratory.kr Address: Daejeon, Republic of Korea Occupation: Executive Director | Founder Affiliation: Health Collaboratory BMJ: Additional Article Info: Rapid response