Towards a coherent global health architecture: perspectives on integrating global health security and universal health coverage through diplomacy and governance reforms.

Within the global health landscape exists a complex interplay between global health security (GHS) and universal health coverage (UHC)-two influential agendas with profound influence on health system strengthening initiatives. There is a need to understand why and how coherence between GHS and UHC is being pursued in health policy and planning, particularly in the wake of the COVID-19 pandemic which profoundly reshaped the field of global health and significant cuts to global health assistance. This paper presents one of the first detailed analyses of contemporary efforts to conceptualize and operationalize GHS-UHC coherence-through the perspectives of key actors responsible for its implementation. The study employed thirty-one interviews with senior officials across four major types of global health actor: multilateral and global health organizations, country governments, donors and international finance institutions, and civil society organizations. It reveals important insights into the way specific actor and geopolitical groups varied in terms of shifting perceptions of GHS and UHC, as well as major factors influencing GHS-UHC coherence (e.g. strategic considerations including motivations and concerns, and structural considerations including enablers and barriers). The analysis suggests that an emerging 'hybrid norm' linking GHS and UHC appears to be well underway. It further contends that strengthening coherence between GHS and UHC not only depends on, but also enhances, three key imperatives: (i) overcoming geopolitical power asymmetries, (ii) leveraging strategic collaboration across actor types, and (iii) pursuing integrative health diplomacy amid overlapping crises. While this study centres on GHS-UHC alignment, its broader objective is to foster a more equitable and resilient global health architecture by tackling the interconnected causes of fragmentation through hybrid normative frameworks. By focusing on the politics of norms underpinning GHS and UHC integration, this work contributes to rethinking how global health institutions collaborate, ultimately helping to build more sustainable global health governance fit to withstand future political, economic, and social challenges.