In May 2025, the World Health Assembly adopted the WHO Pandemic Agreement. It was hailed as a landmark, and in many ways it was. But one article was left unfinished: the system for pathogen access and benefit sharing, known as PABS. That is the part that decides whether countries which share virus samples and genetic data get fair access to the vaccines, tests and treatments developed from them.
A year later, it still was not done. On 1 May 2026, WHO announced that member states had agreed to extend negotiations on the PABS annex, with a new target of the World Health Assembly in May 2027, or a special session earlier. WHO has said that finalising the annex is necessary for countries to proceed with signing and ratifying the agreement.
The delay is instructive. The question at the heart of PABS is the oldest one in global health governance: who gives, who gets, and who decides. And it shows why “including Global South voices” is the wrong goal if it stops at inclusion.
Who sits on the boards
Start with the people who govern the organisations that shape global health. Global Health 50/50’s 2022 report, which examined the boards of organisations active in global health, found that about 75 percent of board seats were held by nationals of high-income countries. Nationals of all low- and middle-income countries combined held 25 percent. Nationals of low-income countries held 2.5 percent. People from the United States alone held 44 percent.
The report also found that women from low- and middle-income countries, who make up 42 percent of the world’s population, held just 9 percent of board seats.
These are not intergovernmental bodies like the World Health Assembly, where every member state has a vote. They are the foundations, partnerships, non-profits and companies that increasingly set agendas, fund programmes and shape the evidence base. And they are overwhelmingly governed from the North.
Formal voice versus real power
The standard response to numbers like these is to add seats. Put more people from the Global South on boards, advisory groups and technical committees. That is necessary. It is also where many reform efforts stop, and that is the problem.
A seat is not the same as power. Power in global health tends to sit in a few places that board composition does not touch.
- Money. Whoever funds a programme can shape its priorities, timelines and indicators, whatever the governance chart says.
- Agenda-setting. Deciding which problems are “global” and which are “local” determines where attention and funding flow.
- Technical authority. Guidelines, evidence reviews and modelling are often produced by institutions in high-income countries, and then applied elsewhere.
- Location. Earlier Global Health 50/50 analysis found that most global health organisations are headquartered in Europe and North America. Proximity to headquarters is proximity to decisions.
A representative from a low-income country can sit on a board and still find that the budget, the agenda and the technical framing were set before they arrived.
Why PABS is the real test
The pathogen access and benefit-sharing negotiations are where this abstraction becomes concrete.
During COVID-19, countries that detected and shared data on new variants did not necessarily receive timely access to the vaccines that followed. Many low- and middle-income countries remember that experience sharply. For them, PABS is about whether sharing biological material creates an enforceable claim on the benefits, or just a moral expectation that wealthier countries and companies can decline when supplies are tight.
For countries that host large pharmaceutical industries, the concern runs the other way: binding benefit-sharing obligations could deter research and investment.
Both positions have a logic. But notice the structure. The countries with the least ability to produce medical countermeasures are negotiating for guaranteed access to products they cannot make themselves. That is what a lack of power looks like in practice. It is not about who is in the room. Everyone is in the room. It is about who has leverage when the room disagrees.
What would shift power, not just presence
If the goal is real influence rather than representation, the agenda looks different.
- Change how money flows. Pooled, long-term funding that recipient countries and regional bodies can direct gives more real power than any number of advisory seats.
- Build production where the need is. Regional manufacturing capacity for vaccines, diagnostics and medicines changes negotiating positions. Countries that can make products do not have to beg for them.
- Move institutions. Locating headquarters, research hubs and technical agencies in the Global South changes who is near decisions.
- Strengthen regional bodies. Regional institutions such as the Africa Centres for Disease Control and Prevention can act as counterweights and negotiate collectively.
- Make benefit sharing enforceable. Voluntary pledges have a poor track record in crises. Binding commitments are harder to negotiate but harder to ignore.
The uncomfortable part for well-meaning institutions
For organisations in the North that support “more voice,” the honest implication is that meaningful change will cost them something: control over budgets, agenda-setting authority, or the prestige of being the place where global decisions are made.
Adding a board member is cheap. Moving a headquarters, pooling funds under someone else’s control or agreeing to binding benefit-sharing is not. The gap between those two sets of actions is the gap between symbolic and real reform.
How an agenda gets set before anyone arrives
It is worth tracing how power operates in a typical global health initiative, because the mechanism is rarely visible in governance documents. The sequence below is a composite, not a specific case.
A large funder identifies a priority, perhaps a disease, a technology or a delivery model. It commissions a landscape analysis from a consultancy or university, usually in a high-income country. The analysis frames the problem, identifies “gaps” and suggests interventions. A partnership is formed, with a secretariat in Geneva, London or Washington. An advisory group is recruited, now with deliberate representation from the Global South. The advisory group reviews a strategy that has already been drafted, with a budget that has already been allocated, against indicators that have already been chosen.
At every stage, the people from affected countries are present. At no stage do they decide what the problem is, how much money goes to it, or how success will be measured.
This is why counting seats can mislead. The most consequential decisions are often taken before governance structures are formed, in funding strategies and commissioned analyses. By the time the board meets, the frame is set.
The strongest counterargument
The case for the current arrangements is not empty, and dismissing it weakens the argument for change.
Money comes with accountability. Funders in high-income countries answer to taxpayers, parliaments or donors, and they are expected to show results and prevent misuse. Concentrating decisions where the money originates is, on this view, a matter of responsibility, not domination. Some governments in the Global South have weak public financial management, and some have used health funds poorly. Technical expertise is also unevenly distributed, and pooling it in a few institutions can be efficient.
Parts of this hold. Accountability for public money is legitimate. Corruption and weak management exist, in the Global South and elsewhere. And some centralised technical functions, such as prequalification of medicines, do benefit from scale.
But the argument has blind spots. Accountability to funders is not the same as accountability to the people whose health is at stake, and the current system provides much more of the first than the second. Weak institutions are partly a consequence of decades of funding that bypassed governments rather than strengthening them. And technical expertise in the Global South is far greater than its representation in global institutions suggests. The problem is less a shortage of expertise than a shortage of positions from which that expertise can decide things.
The more defensible position is that accountability and power-sharing can coexist. Funders can retain oversight of how money is used while ceding control over what it is used for.
Second-order effects
Priorities skew. When agendas are set far from where disease burden falls, attention tends to go to problems that are visible to funders, measurable within short grant cycles or aligned with the funders’ own interests, such as health security threats that could reach high-income countries. Conditions that matter enormously locally, but less to funders, get less.
National systems fragment. Multiple initiatives, each with its own priorities and reporting systems, can pull ministries in different directions and absorb scarce staff time in managing donors rather than delivering services.
Dependency persists. When external actors control funding and technical direction, national institutions have fewer opportunities to build their own capacity to lead. The absence of capacity is then used to justify continued external control.
Legitimacy suffers. Global health institutions that are seen as instruments of wealthy countries find it harder to secure cooperation when they need it most, including during pandemics.
What this means for different decision-makers
For health ministries in the Global South, the practical lever is often coordination. Ministries that insist on a single national plan and a common set of indicators, and require partners to align, have more influence than those negotiating separately with each funder.
For regional bodies, collective negotiation matters. Countries negotiating as a bloc, on procurement, pathogen sharing or financing, have leverage that individual countries lack.
For funders, concrete steps include moving decision-making authority, not just advisory roles, to regional offices or partner institutions; funding through national systems where feasible; and accepting indicators and priorities set by national governments.
For global health organisations, a useful internal audit asks: where are our decisions actually made, by whom, and where do those people live? The answer is often more revealing than the composition of the board.
For health professionals, there is a role in insisting that partnerships, research collaborations and training programmes are designed with, not for, colleagues in the Global South.
What to watch next
The PABS negotiations are the most visible test. Watch whether the final annex includes binding benefit-sharing commitments, or relies mainly on voluntary pledges. Watch the growth of regional manufacturing for vaccines and other medical products, which changes negotiating power more durably than any governance reform. And watch where new global health institutions and funds choose to locate their headquarters and senior staff. Location is not everything. But it is a signal of who is expected to lead.
The expertise that is already there
One misconception deserves to be retired. Discussions about Global South voices sometimes imply that the task is to find or develop people who can take part in global governance. In reality, ministries, universities, regulators and public health institutes across Africa, Asia and Latin America already hold deep expertise in running health systems under constraints that most high-income countries have never faced. Many managed epidemics, vaccination campaigns and health reforms with far fewer resources.
The problem is less the absence of that expertise than the absence of mechanisms that let it shape global decisions. Fixing that is a design question for global institutions, not a training question for everyone else.
The takeaway
Global South voices in global health governance are not missing. They are present in assemblies, on panels and increasingly on boards. What is missing is the power that should come with them: control over money, agendas, production and the rules that apply when supplies run short.
The PABS negotiations will be a useful test of whether that is changing. Watch less for who speaks, and more for what becomes binding.
Where have you seen real decision-making power, not just representation, shift toward the Global South? We’d like to hear examples.
