In September, I wrote that the G20 could and should play a leadership role in global health. Representing 90% of the world’s economy, nearly 70% of the world’s population, and 92% of official development assistance, what the G20 says and does in global health matters. On top of the intrinsic value of good health, leadership by the G20 in global health would also reflect the vital role that health plays in economic development.
The Brisbane G20 provides an opportunity to reflect on the G20’s potential role in global health. As had been called for by advocates and anticipated by analysts, ebola featured on the agenda in Brisbane. But has its inclusion been commensurate with the nature of the problem and the required response? And in what other ways has health been incorporated into the G20’s agenda?
The G20 Leaders’ Statement on Ebola highlights the outbreak’s ‘social, humanitarian and economic impacts’. The Statement expresses support for the ongoing work of the WHO and the UN Mission for Ebola Emergency Response, and called for governments and international financial institutions including the World Bank and International Monetary Fund to provide support. Importantly, the Statement moves beyond short-term control measures and highlights the importance of longer-term health systems issues including addressing capacity gaps in capability, preparedness and response.
Ebola is also included in the Leaders’ Communiqué.
We are deeply concerned with the humanitarian and economic impact of the Ebola outbreak in Guinea, Liberia and Sierra Leone. We support the urgent coordinated international response and have committed to do all we can to contain and respond to this crisis. We call on international financial institutions to assist affected countries in dealing with the economic impacts of this and other humanitarian crises…
Worryingly, the Leaders’ Communiqué ignores the longer term systems approach called for in the Ebola Statement.
A key weakness of the ebola commitments is the absence of any sort of measurable outputs. While the Brisbane Summit concluded with a range of specific commitments which together aim to increase global economic growth by 2.1 per cent (on top of business as usual) over the next five years, the ebola commitment lacks specific targets and accordingly appears short on accountability measures – how will the G20 define success, and evaluate its contribution? As Larry Gostin and colleagues recently argued, a sustainable response to ebola and other infectious diseases requires ‘binding commitments for funding and technical assistance to build national preparedness capabilities, including surveillance, laboratories, health systems, and rapid response.’ The G20’s commitment does not appear to contribute to the binding commitments needed to improve global health governance.
Research by John Kirton and colleagues, on the global health commitments of the G8, is a useful reference point. They surveyed the G8’s global health commitments from 1996-2006 – a period in which the Group focused particular attention on global health – and determined three factors that act as facilitators of compliance on health pledges.
- Setting a one year timetable for compliance. Given the short term/long term approach needed to address ebola, two separate timetables might have been appropriate – a short term commitment of, for instance, dollars and personnel; and a longer term commitment of support for strengthening health systems.
- Seeking the support of the WHO in implementation. Given the references to the WHO in the Ebola Statement, it seems likely that any pledges will at least indirectly involve the WHO. Given, however, that one of the reasons that has been put forward for the slow and uncoordinated response to the ebola crisis is the weakness of the WHO (including budget cuts to its infectious disease unit), the G20 would have been a useful forum in which to generate specific funding for the WHO’s role in tackling ebola.
- Create a G8 health ministers institution. The G20 could consider establishing a specific intra-Group health ministers forum. While in 2010 the G20 established a Development Working Group, which aims to agree upon a global development agenda, this group has not focused on health issues, and it’s notable that the Working Group’s Brisbane Update did not specifically include ebola or global health more generally.
Global health features in other areas of the Brisbane G20 agenda. For instance, the Leaders’ Statement notes that ‘Improving workplace safety and health is a priority’ and states that the G20 Food Security and Nutrition Framework will focus on food systems and food supply. The much-discussed climate change commitment also has obvious relevance for public health, though is framed in an economic rather than public health context.
The Leaders’ Communiqué expresses support for the post 2015 development agenda – in which health goals are expected to be prominent – though seems to suggest that its role will be limited to ‘strengthening economic growth and resilience.’ With this agenda now being finalised, the question should be asked: will the G20’s commitment move beyond economics and include the development of a broader human development framework, and include the mobilisation of resources for this development agenda?
The ebola outbreak has made it clear that the G20 cannot distance itself from the global health agenda – both because of the links between health and the economy, and because of the moral imperative. The imminent finalisation of the post 2015 agenda provides an opportunity for the G20 to further develop its thinking in global health – including moving beyond responding in an ad hoc manner to the most ‘pressing’ crisis of the day, and instead developing a strategy that reflects the nature of the global burden of disease and the long term investments required to enable health systems to adequately address this burden.
Sam Byfield is a global health consultant, an Associate of the Nossal Institute for Global Health, and is completing a Masters in International Law at the University of Melbourne.
Thanks Ben and Joel. I agree with you both about the over-crowded global health architecture, but tend to disagree with the idea of scrapping the WHO – i think with proper funding, staffing and mandate, the WHO has the potential to add order to the chaos of global health. And I’m a supporter of its normative role, like leading development of the Framework Convention on Tobacco Control. I’d agree that, with a few exceptions, it hasn’t lived up to its potential, but i think at least some of the reasons for that are outside of its power.
Yes, I agree WHO is not fully to blame for its shortcomings. And I do think that the criticism based on the slow Ebola response has been excessive. But even given all that, I would like to think that after 65 years, supporters would be able to raise more than the normative role and the Framework Convention in the list of achievements / arguments on why WHO is needed. Gostin always does the same as do many others. I think those who support WHO need to show more evidence of success beyond one Convention and a normative role that means little if it is reactive, behind-the-times and inefficient.
OK, that’s my WHO rant for the day. I do take your point and Ben’s point that the G20 represent money and leadership and therefore might be a good mechanism for action and advocacy.
Thanks for a thought-provoking article.
Agree the global architecture is extremely crowded; the central problem is that it is crowded by actors with limited political influence. Forums like the G20 are critical mechanisms to build on a tecnical agenda set by the actors Joel mentions, with financing and leadership. The way in which the Ebola debate is coalescing around neglected health systems is, despite the horrific crisis, encouraging for the long term. Link that to an increasing interest in global health security, and we have the potental for a powerful combination of leadership, financing and the political clout of large nation states. At this stage unfortunately, potential only.
Interesting post. For me, raises broader issues of the global architecture for health – which is exceedingly complex and already has a huge number of actors. This is not necessarily bad – in some cases it can be good – but it is certainly complex and does have some down sides. From WHO to Gates to various parts of US government (USAID, PEPFAR, CDC) to Institute for Health Metrics and Evaluation to GAVI to Global Fund to World Bank to ADB to other bilaterals to UNICEF to UNFPA to the various smaller actors. Global health is messy. As is, at the country level, they are bombarded with requests, declarations, invitations, initiatives. The problem – especially from a long-term systems building perspective that you very rightly promote – is that ministries and implementers get pulled in a hundred different ways.
While I agree that the G20 has something to possibly offer, the thought of additional mechanisms, meetings, committees (such as G20 health ministers forum or G8 equivalent) fills me with dread. The only way I could see that being useful would be if some other mechanisms were eliminated (which virtually never happens in our global architecture). If you want a G20 health body, then abolish the Global Fund or equivalent (or better yet abolish the WHO).
Otherwise, I would argue that we should ensure that the already-too-many mechanisms are running effectively and are actually improving systems on the ground.