The HEAR CSO Global Survey gathered perspectives from civil society organisations, community networks, impacted communities and other global health actors on the future of global health architecture. It aimed to widen participation beyond HEAR CSO’s 2025 virtual consultations and capture a broader range of perspectives on how the current architecture functions and where change is needed.

The survey explored three areas: who responded, how familiar respondents are with global health architecture and related reform processes, and how they assess the current system and future reform priorities. It combined structured questions with open-ended responses to capture both comparable data and more detailed reflections.

The survey was open from 22 January to 2 March 2026. It was available in 10 languages, and responses were received in five.

Who responded?

The survey reached a broad cross-section of people working across global health policy, advocacy and service delivery. The majority of respondents identified as part of civil society, alongside a smaller number of participants associated with public institutions, multilateral bodies or local consulting firms, technically classified as private sector.

Respondents represented organisations working in more than 70 countries and across a wide range of health issues, including HIV/AIDS, primary health care, climate and environmental determinants, nutrition, and pandemic preparedness.

Geographic reach

Respondents represented organisations working across multiple regions. The largest share identified their scope as Global (19.7%), followed by Western Africa (16.8%), Eastern Africa (12.3%), and Southern Africa (9.8%). Latin America and the Caribbean, South Asia, and Central Africa each accounted for around 8–9% of responses.

Additional responses came from Eastern Europe and Central Asia, North America and Western Europe, the Middle East and North Africa, and Asia-Pacific. These categories are analytical groupings used to support comparison across the dataset.

Health areas represented

Respondents worked across a wide range of health issues. The most frequently represented areas were HIV/AIDS (56.8%), primary health care / preventive health (49.5%), sexual and reproductive health and rights (SRHR) (49.5%), noncommunicable diseases (NCDs) (44.2%), and universal health care (41.8%).

Respondents could select more than one health focus area. These categories therefore overlap and are used to show the breadth of perspectives represented in the survey, rather than distinct comparison groups.

The profile shows that the survey captured a diverse mix of regional and thematic perspectives, with particularly strong representation from civil society actors working across major health equity issues.

Readiness is high. Participation is still limited.

Most respondents demonstrate readiness to engage in global health architecture reform. Across the survey, 73% of respondents fall into either moderate or high readiness, including 34% in the highest readiness category.

However, only 8.5% report direct participation in processes explicitly framed as global health architecture reform.

This gap indicates that interest, experience and motivation extend well beyond those currently visible in formal reform spaces. The constraint is not simply whether civil society and impacted communities are ready to engage, but whether reform processes are accessible, clearly defined, and open to meaningful participation.

“I have not participated in a process explicitly labelled as global health architecture reform, but I have engaged in policy dialogues on health systems strengthening, SRHR financing, and primary health care reform. These discussions intersect with broader global health governance and financing issues.” – Western Africa CSO

Qualitative responses help explain this gap. Several respondents describe the term “global health architecture” as unfamiliar or abstract, which limits how people identify their own participation. Others point to governance spaces where civil society is present but does not meaningfully influence decisions.

Across regions, the pattern remains consistent: readiness to engage is substantially higher than direct participation in reform processes.

Across the survey, respondents consistently recognise both major achievements and serious structural pressures. Together, these responses point to a shared understanding of the current system: one that has delivered important results through multilateral cooperation, but is under strain.

Most respondents recognise the value of global institutions and norms.

• 93.7% agree that global agreements affirm key aspects of the right to health for all.
• 91.6% agree that WHO plays a vital role as the global authority for health rules and standards.
• 90.9% agree that multilateral institutions such as Gavi and the Global Fund have delivered meaningful results through collective action.

Respondents also recognise progress through childhood vaccination programmes and targeted investments in HIV, TB, malaria and maternal health.

At the same time, they express equally strong concern about the system’s current trajectory.

• 93.7% agree that a funding crisis is putting hard-won gains at risk.
• 90.2% agree that agreements intended to promote global health equity are often not enforced, financed or prioritised.
• 87.0% agree that global health governance has not kept pace with changes in who pays, decides and implements.

Respondents also consistently highlight workforce pressures and the reduction of resources for community-based and community-led services.

These findings show that respondents do not view the current global health architecture as either failing or succeeding. They describe a system that has delivered results, but is struggling to adapt and respond equitably to current pressures.

“Multilateral organizations/funding partnerships have achieved results, but not all of them are built on a mindset of national and local leadership; and there are potentially also too many structures and institutions, although they currently all play important roles of pooling funding and expertise. More collaboration and alignment and more regional, national (incl. local-level and CS/community) leadership is needed.” – Western Europe CSO

While many statements show strong agreement, others reveal lower consensus, greater disagreement, or more uncertainty. These areas cluster around pandemic preparedness, support for frontline and community-based delivery, and whether the system can deliver equitable access and more integrated care.

The clearest area of weak confidence is preparedness for future crises. A majority of respondents do not believe that the current system is sufficiently prepared for the next pandemic or outbreak. This represents the sharpest signal of concern across the survey.

Views are also divided on whether community health workers, peer educators and civil society networks are adequately resourced to deliver services. While some respondents report sufficient support, many others do not, highlighting uneven experiences across contexts.

Respondents also express lower confidence in whether:

• funding is shifting towards more integrated health services rather than remaining disease-specific
• global coordination mechanisms can ensure access to medicines and vaccines for all
• the system is set up to deliver equitable access during a global pandemic

These findings do not suggest that these issues matter less. Instead, they point to areas where progress is uneven, and where confidence in the current model is weaker.

“Community health workers etc are “resourced”, but nowhere near “sufficiently resourced”. – Global CSO

Across the reform pathways, respondents align most clearly around a set of directional priorities: strengthening domestic financing, expanding the definition of global public goods, reinforcing regional coordination, and investing in community-led and nationally embedded systems.

This pattern suggests that respondents are not primarily calling for incremental adjustments within the current architecture. Instead, they prioritise reforms that shift power, strengthen country and regional agency, and improve how systems function in practice, particularly for marginalised communities.

“Decision-making power needs to shift — or at least be shared more fairly — between the global North and South, with greater focus on country priorities rather than donor priorities.” – Global CSO

Governance

No single governance proposal reaches the same level of consensus as the strongest priorities in other domains.

The highest-ranked proposal is “Shift to collective bargaining at regional level” (53% top priority), where regional blocs aggregate country positions and negotiate with global institutions and funders. This reflects a clear demand for stronger regional voice in global decision-making.

Other proposals show more mixed support:

• “Align all global support to costed national or regional plans” (36% top priority) attracts steady support with relatively low opposition
• “Strengthen civil society roles in decision-making structures” (38% top priority; 45% lower priority) is important but polarising
• “Consolidate Global Fund and Gavi into a single financing mechanism” (49% top priority; 42% lower priority) is the most clearly divided proposal

“Integrate climate and health into planning and budgeting” ranks lowest in this domain, likely reflecting sequencing or perceived immediacy rather than lack of importance.

Financing

The strongest signal across the entire survey appears in financing.

• “Increase domestic financing for health at national level” (69% top priority) is the most widely prioritised proposal
• “Find or scale financing approaches that work in middle-income contexts and mixed-income regions” (55% top priority) follows as a clear second priority

Other proposals receive more mixed rankings:

• debt restructuring
• tax and tariff reform
• solidarity funds for marginalised or criminalised groups
• reducing fragmentation of vertical programmes

These lower rankings do not indicate rejection. Rather, they suggest that respondents see these pathways as more politically complex, longer-term, or harder to advance through the health sector alone. The financing section also combines structural outcomes and specific mechanisms, which may have influenced how respondents prioritised options.

Access to global public goods

Respondents show the strongest alignment in this domain.

• “Agree on a common definition of global public goods, supported through fair-share contributions” (72% top priority) is the highest-ranked proposal in the access section
• “Use regional platforms to coordinate licensing, regulatory approval and procurement” (62% top priority) also receives strong support

Together, these findings point to two linked priorities: expanding what counts as a global public good, and strengthening regional systems to operationalise that definition.

More technical proposals — such as applying intellectual property flexibilities more consistently or improving coordination between licensing, regulation and procurement — receive more mixed responses.

Implementation and service delivery

Respondents prioritise delivery models that are locally rooted and nationally embedded.

• “Ensure sufficient funding for community-led and community-designed services” (60% top priority)
• “Use national delivery platforms, data systems and workforces for all health investments” (55% top priority)

These priorities reinforce a consistent message across the survey: respondents favour systems designed with and through communities, rather than parallel or externally driven structures.

Other proposals — including strengthening primary health care, legal reform, and long-term workforce and management capacity — receive moderate or lower top-tier rankings. These results likely reflect sequencing and feasibility considerations, rather than lack of importance.

“Delivery works when frontline systems are scaled, paid, skilled, and supported — not built on short-term projects or parallel structures.” – Global CSO

How to read this chart

Proposals further to the right received higher levels of priority. Proposals lower on the chart have lower average rank scores, meaning they were placed closer to the top of respondents’ priority lists.

Across the full sample, proposals linked to domestic financing, expanded global public goods, community-led services, and national delivery systems cluster most closely in the highest-priority area. Governance proposals are more dispersed, and several financing and access proposals appear more polarising.

Familiarity note

Across familiarity levels, domestic financing, a broader definition of global public goods, and community-led services continue to attract strong support. This suggests that these priorities reflect widely shared perspectives across civil society, not only technical or insider preferences.

Across regions, patterns vary and some proposals become more or less polarising depending on context. However, the overall direction is consistent: respondents prioritise reforms that strengthen regional voice, national system capacity, and community-led delivery, while showing more mixed views on specific institutional pathways.

About the data

This analysis draws on the HEAR CSO Global Survey, which gathered responses from civil society actors, community networks, impacted communities, and other stakeholders working across global health. The final dataset includes 285 cleaned responses, representing organisations working in more than 70 countries.

Data cleaning

Responses were systematically reviewed prior to analysis to identify and remove potential duplicates and improve consistency.

Potential duplicate submissions were assessed using a combination of identifiers, including name, email address, organisation, and country. Where multiple responses appeared to come from the same individual, a single entry was retained based on completeness, internal consistency, and factual accuracy.

Where possible, participation in HEAR CSO consultations was cross-checked against attendance records. No decisions about inclusion or exclusion were based on respondents’ views or positions.

Classification and grouping

Responses were grouped using reported organisation type, geographic scope, and other profile information.

To support comparison across the dataset, responses were organised into harmonised regional categories. These categories are analytical groupings developed for this survey and do not necessarily reflect how respondents define their own region or identity.

Organisations working across multiple countries or regions were grouped as Global.

For questions allowing multiple responses, each selected option was counted separately. As a result, percentages in some sections (such as health focus) may exceed 100%.

How responses were analysed

This analysis combines quantitative and qualitative approaches.

Quantitative analysis includes response distributions and ranked priorities across the four reform domains. It also includes an exploratory readiness-to-engage grouping, based on respondents’ familiarity with and reported engagement in global health architecture discussions. This grouping is intended as an analytical tool to identify patterns across the sample, rather than a definitive classification.

Qualitative responses were analysed thematically to identify recurring ideas, areas of agreement, and points of divergence. Where important themes emerged that were not fully captured by predefined response options, additional categories were developed during analysis.

How to read the findings

These findings present patterns across the survey sample. They do not aim to provide statistically representative estimates of all civil society perspectives globally.

Participation varies by region, organisation type, and health focus. As a result, some perspectives are more visible than others, and findings from smaller subgroups should be interpreted with particular care.

The regional categories used in this analysis are simplified groupings designed to support comparison. They should not be interpreted as fixed political, geographic, or identity-based classifications.

Qualitative findings are interpretive and based on thematic analysis. They provide context and depth to the quantitative results but do not capture the full range of views expressed.

As with any survey, question wording and framing may influence how respondents interpret and answer specific items, particularly in sections related to global health architecture and reform.

You can find the full report which includes the findings from our regional consultations below. You can find our principles here.