Can HEOR Support Multilateral Institution Reform?

Kelly Saldaña, Executive Director, ISPOR Institute for Healthcare Transformation

The current wave of global health reform debates isn’t an intellectual exercise—it’s being driven by the new reality of a sharp contraction in funding. This new reality is increasing pressure on global health institutions. But it’s also creating opportunities.

In 2025, multiple donor governments enacted sudden and, in many cases, severe cuts to global health financing. The United States’ withdrawal from the World Health Organization (WHO) and pull back of bilateral funding was the highest in profile but wasn’t an isolated case. In the wake of these cuts, WHO warned of “severe disruptions” to essential services in roughly three-quarters of the world’s countries and issued guidance on immediate and longer-term responses to sudden aid reductions. Model-based analyses estimate substantial potential mortality impacts, although estimates vary by scope and assumptions. For example, trackers of USAID funding freezes suggest large excess deaths from HIV and tuberculosis in 2025; one scenario analysis projected up to 25 million additional all-cause deaths over 15 years if all US global health funding ceased, and another noted up to 14 million additional deaths by 2030.

Given the potentially dire impact of these funding cuts, it’s more important than ever to ensure that major multilateral institutions, such as Gavi, the Vaccine Alliance, and the Global Fund for AIDS, Tuberculosis, and Malaria, are structured to maximize value. Two recent commentaries outline considerations for reforming the global health ecosystem with this objective in mind.

With less money and more volatility, global health institutions must be more aligned, more disciplined, and more accountable to country defined priorities and delivery constraints.

In a June 2025 Lancet commentary, “The Gavi Leap: radical transformation for a new global health architecture,” Sania Nishtar, Gavi CEO, calls for a radical transformation of Gavi as a catalyst for a broader shift in how global health institutions work together.

Recently, in January 2026, African health and finance officials, Muhammad Pate and Donald Kaberuka, along with former UNAIDS executive director, Peter Piot, writing in Think Global Health, outlined 10 considerations for reforming the global health ecosystem, arguing somewhat ambitiously for a rapidly transformed ecosystem—one that reenergizes global health efforts by aligning resources, leadership, and innovation.

Taken together, these contributions point to a shared reality: With less money and more volatility, global health institutions must be more aligned, more disciplined, and more accountable to country-defined priorities and delivery constraints.

From Fragmentation to Convergence: The Role of New Multistakeholder Conveners

The decline of multinational collaboration through aligned programs, such as Gavi, the Global Fund, and signature US global health initiatives like the President’s Emergency Plan for AIDS Relief, the President’s Malaria Initiative, and retrenchments in bilateral financing across many donors, have exposed the limits of the legacy system for global health programming.

Nishtar’s focus on a “new global health architecture” highlights the need for mission-driven coalitions that can act decisively in a constrained environment. Pate, Kaberuka, and Piot emphasize that reform efforts must be practical and action-oriented, offering concrete considerations for how governance, financing, and collaboration should evolve to create a more effective ecosystem.

The need for reform of existing institutions also opens space for new forums for convening multistakeholder groups—spaces that bring together:

• Governments and payers

• Implementers and civil society

• Researchers and HEOR experts

• Industry and innovators

• Clinicians and public health program managers

• Communities, caregivers, and patients

Organizations like ISPOR—The Professional Society for Health Economics and Outcomes Research already demonstrate the capacity to convene diverse actors around shared methods and evidence through our task forces, special interest groups, councils, and roundtables. ISPOR’s global network allows it to draw on local analytic capacity to support genuine country ownership.

The new ISPOR Institute for Healthcare Transformation (www.ISPORinstitute.org) can work through existing bodies and networks to support:

• Country-led, evidence-informed priority setting

• Shared methodological standards for value assessment

• Cocreation of organizational infrastructure (information systems, organizational processes) to support evidence-based decision making

• Translation of HEOR insights into policy and practice

HEOR’s Unique Contribution: Setting Priorities in a Constrained World

In an environment of tightening budgets and rising expectations, health economics and outcomes research (HEOR)—especially cost-effectiveness analysis (CEA), paired with budget impact analysis and equity-sensitive approaches—can serve as a foundation for reforms that help to maximize efficiency, effectiveness, and value throughout the global health ecosystem.

This begins with clarity on perspective: Whose costs and benefits count? Perspective determines whether analyses reflect the budgets and constraints of ministries of health, ministries of finance, donors, health systems, households, or society as a whole. Aligning on perspective reduces misunderstandings, helps donors see where their priorities may diverge from country needs, and ensures that global public goods/programs are valued appropriately, even when national CEA alone may undervalue them.

Through multistakeholder dialogues, country teams (alongside major multilateral institutions and donors) can discuss their different perspectives and agree upfront on the key aspects of value. Establishing a shared value framework gives all actors a common basis to compare and prioritize interventions, and move from fragmented, intervention-by-intervention decisions toward coherent, system-wide prioritization.

Deciding What to Measure and Value

HEOR frameworks require explicit choices about what outcomes to value:

• Traditional clinical endpoints

• Quality-adjusted life years and broader “whole health” outcomes

• Patient-reported outcomes and functioning

• System-level benefits like resilience and continuity of care

The outcomes we choose to measure shape what is ultimately prioritized. Narrow outcomes tend to favor vertical programs and technologies. Broader outcomes can capture the full value of integrated platforms such as primary healthcare and noncommunicable disease management. Making these choices explicit helps ensure that priorities reflect what countries and communities value most.

Establishing a shared value framework gives all actors a common basis to compare and prioritize interventions and move from fragmented, intervention-by-intervention decisions toward coherent, system-wide prioritization.

Deciding What to Include from a Public Health Perspective

Similarly, HEOR forces clarity about which public health effects are in or out of scope, such as:

• Prevention benefits and herd protection

• Spillover effects on other services (eg, decongesting facilities)

• Economic and social participation gains

• Cross-sectoral benefits (education, productivity, social protection)

The explicit inclusion of broader public health effects strengthens the case for health investments to ministries of finance, which must weigh competing development priorities by demonstrating health’s contribution to national development agendas. It also helps clarify which programs deliver genuine cross-cutting or system-wide benefits that may not be visible when evaluated within narrow disease silos. By making these effects explicit, HEOR can distinguish interventions that create broad population-level value, and can highlight opportunities where integrated, cross-program investments yield greater overall impact.

Agreeing on Thresholds and Their Interpretation

HEOR also brings structure to debates over “how much is enough,” especially in resource-constrained environments:

• What constitutes “good value” in a low- or lower-middle–income setting?

• How should cost-effectiveness thresholds relate to local budget constraints and opportunity costs?

• How do equity concerns shape those thresholds?

Multistakeholder groups (including ministries of health and finance, civil society, and technical partners) can deliberate and agree on context-appropriate value thresholds, which can support strategic purchasing and benefit package design while also providing a mechanism to identify funding gaps and where additional donor resources would have the most impact, especially for health system-level programs that support multiple disease areas.

From A Priori Decisions to Aligned Action

When you combine these a priori decisions, HEOR becomes a mechanism for convergence: moving away from silos and fragmentation.

A shared evidence base. Nishtar’s call for a “leap” in global health architecture hinges on institutions being able to coordinate around clear missions and shared metrics. CEA offers a common analytic language for comparing the value of different investments, whether they are vaccines or medicines, primary care platforms, digital health tools, or community health worker programs. This is particularly true for the foundational interventions that support multiple disease-specific programs and are geared toward strengthening the overall health system.

Country-driven priority setting. Pate, Kaberuka, and Piot envision a transformed ecosystem where global health efforts are reenergized through better alignment of resources, leadership, and innovation. CEA and related HEOR methods (like budget impact analysis and distributional cost-effectiveness) allow countries to ground decision making in local data and resource constraints, rather than developing unrealistic plans that attempt to respond to all priorities simultaneously. Global institutions can then align their programming to country-level decisions and country-defined priorities and constraints, reducing fragmentation and transaction costs.

Global-country alignment across disease programs. Multistakeholder groups across the global health ecosystem can evaluate different interventions based on clear and transparent understandings by agreeing (or at least understanding the different perspectives) in advance on:

• What outcomes count

• Which public health effects are included, and

• How thresholds will be interpreted.

This helps avoid the pattern where every disease area develops its own, isolated logic, where countries are caught between different incentive structures, without a means to articulate the divergence, and efforts become either duplicative or hopelessly fragmented. At the same time, such an approach allows for both national and global level decision making. Some investments require a broader lens than national CEA alone. Interventions that reduce antimicrobial resistance, prevent outbreaks, strengthen surveillance, engage in vector control, ensure vaccine availability, or maintain other global public goods may appear marginal from a purely national perspective but yield critical regional and global benefits. In such cases, global subsidies or donor financing may remain justified, even if a country’s own willingness-to-pay threshold would not prioritize the intervention.

We have a real opportunity to move from fragmentation and crisis management toward a more coherent, efficient, and equitable global health ecosystem.

ISPOR and the ISPOR Institute: A Platform for Locally Grounded, Globally Relevant Reform

This is where ISPOR and the ISPOR Institute for Healthcare Transformation can make a distinctive contribution:

• Convening power: Bringing ministries, payers, implementers, researchers, and industry together around shared HEOR methods and questions, but most importantly, to seek consensus on value frameworks up front.

• Methodological rigor: Based on agreed value frameworks, leveraging context-appropriate HEOR tools and methods such as CEA, budget impact analysis, real-world evidence, and equity-sensitive approaches to support transparent, defensible decisions.

• Local capacity: Tapping into ISPOR’s extensive regional and national networks (including 20,000+ members and 76 regional chapters across 100 countries) to ensure that analyses reflect local realities, data, and constraints—not only global averages—while also supporting connection points to a global network of experts.

• Global dialogue: Ensuring that all the key stakeholders that need to come together in this new era for global health funding have a seat at the table; connecting country-level decision makers to global discussions while ensuring that discussions on architecture are grounded in real policy and budget decisions at country level.

In an era of fiscal tightening and political volatility, this kind of locally grounded, globally connected HEOR platform can help turn high-level reform aspirations into workable, country-centered implementation pathways.

Call to Action

We are entering a period where the global health community is being forced to make choices—and to do so in ways that are transparent, fair, and grounded in evidence and that maximize the health value obtained from scarce resources.

CEA and broader HEOR methods provide a disciplined way to frame, debate, and act on a set of shared values. If global health institutions, countries, and partners embrace HEOR as part of this reform moment, we have a real opportunity to move from fragmentation and crisis management toward a more coherent, efficient, and equitable global health ecosystem.

The ISPOR Institute for Healthcare Transformation stands ready to act as a neutral convener for these discussions, supporting them with methodological and scientific experts from around the world.