This introduction explores the changing landscape of global health governance since the early 2000s, highlighting the growing influence of various international actors beyond the World Health Organization (WHO). It critiques the shift from a multilateral public model to a public–private–philanthropic framework. Key areas of concern include the fragmentation of authority, the reduction in public funding of the WHO and difficulties in ensuring equity in access to health. The text highlights tensions in the ongoing negotiations on pandemic preparedness treaties and revisions to the International Health Regulations, highlighting the geopolitical divide between developed and developing countries. It advocates regional health initiatives as a response to the multilateral impasse and reflects on the erosion of foundational public health concepts such as “essential medicines”. The chapter aims to inform policy debates on safeguarding universal access to health and strengthening regional and multilateral solutions.