The patchwork of global health policymaking
The world is changing dramatically, and never has the need for greater integration, coherence and cooperation from our global organisations been more critical. There is no easy solution, but bold steps are worth taking
The calls for more integration, coherence and cooperation in matters of global health are intensifying as the global health universe expands. Discussion about which of the many existing bodies – new and old – is the most appropriate for taking certain agendas forward becomes ever more contested, especially as frustration mounts over the lack of progress, particularly in global health. Many questions have arisen in recent years. Which is the best place for global policymaking on health as the issues expand far beyond traditional health policies? Is it better to negotiate within the World Health Organization? Would a high-level council at the United Nations really make a difference? Can political clubs such as the G7 and the G20 achieve more than staid UN bodies? Are totally new bodies needed to reflect the geopolitical powershift? Does decision-making improve when the number of stakeholders is expanded? Does fragmentation reflect a lack of political will to address global challenges jointly? There is probably only one issue on which nearly everyone agrees: reforming the UN Security Council. And that is probably the most difficult reform of all.
Excitement was high in global health circles when health was finally regularly included in UN deliberations and at the G7 and the G20. An analysis of the most recent outcomes of the meetings in 2023 have poured some cold water on that enthusiasm. The results are bland and meagre compared to the challenges at hand: the financing crisis of health systems, the tragic cycle of increasing poverty and ill health, the expansion of profitable industries that produce non-communicable diseases and the devastating climate and health nexus, the rollback of the right to health. Indeed, the situation was so bad that the fact that there were declarations at all was considered a success. Yet the skies over New York were filled with colourful drone messages as the 2023 UN General Assembly opened.
Perhaps we do need to celebrate the fact that countries are still talking despite the strong nationalist tendencies, the North-South divide, conflicts between the West and China, and the impacts of the war in Ukraine. This is today’s real world, defined not by the haze of hegemony but by deep differences and power inequalities, which are no longer accepted. The inability to reach consensus is an expression of that powershift. Politics and ideology are back with a vengeance, and play out in global health over issues of intellectual property, sexual and reproductive health and rights, access to technologies and much more. For too long they have been glossed over until Covid-19 brought them to the fore. Yet many organisations and negotiators are inadequately prepared for differing values and competing world views. They have forgotten that this was why many organisations were created in the first place: to address conflicts and play out power dynamics. This is a new phase of global health diplomacy.
TO SOLVE COMMON PROBLEMS
The role of the UN organisations shifted dramatically from their post-war function to resolve political conflicts before they turn into military action to producing global goods. This is one reason that global governance has been approached in a very functionalist manner without regard to power differences: the priority to deliver the international cooperation required to produce results to solve common problems. Consequently, a very managerial approach built on goals, targets and investment cases was institutionalised. In many cases the targets were bold – the Sustainable Development Goals are a testimony to that – but the mechanisms to reach them have not followed the same level of ambition. This imbalance has redefined global solidarity and contributed to a development that has made the UN the major provider of humanitarian support – first and foremost food, shelter and medical care – as one emergency follows another.
The failure to reach the objectives is consistently put down to political will. Yes, many countries could and should be doing more to ensure planetary and human health, both at home and together. The political declarations on universal health coverage and pandemic prevention at UNGA reiterate health as a universal goal – that everyone wants for themselves and for others, from individuals to states. But those declarations leave it at statements about redoubling efforts for universal health coverage and prioritising preparedness. The polarisation after Covid has shown clearly that health has become a key area of action where the stark inequalities of the global system become tangible. All the development aid for health, all the philanthropy and charity were reduced to Band-Aids as the power divide played out through vaccine nationalism and the lack of access to medical countermeasures. This is why negotiations for a pandemic accord are so controversial and difficult – power and politics are back because global norm setting is more than a functional enterprise. The stakes are very high, as are emotions and frustrations. But the UN Pandemic Summit did one thing right: it was bland because the negotiations on a pandemic accord are at the World Health Organization, to which it gave priority. Attempts at forum shifting did not work. Indeed, the summit was badly timed and probably unnecessary at this point.
THE EMERGING POLITICAL MESSAGE
The emerging political message is clear: before new debates arise about integration, coherence and cooperation in matters of global health and the reform of its institutions, two basic issues of inequality need to be addressed: representation and democratic governance and the elementary financial determinants of the system. At UNGA, Angola’s President João Manuel Gonçalves Lourenço highlighted the lack of sufficient representation in global governance institutions to contribute to formulating realistic solutions to their problems. The G20 has addressed this by inviting the African Union to join. The BRICS is working on broadening its influences as a voice of the Global South by expanding its membership. The G7 in turn is refining itself as a forum of democracies.
William Ruto, president of Kenya, stated it clearly at the Climate Ambition Summit: “Neither Africa nor the developing world stands in need of charity, handouts or harms from the developed countries. What we need is fairness: a fair financial system; fair market access for green assets, products and services; fair national regional trade mechanisms.” Barbados prime minister Mia Mottley in turn called for a loss and damage fund following the Bridgetown Initiative and said “it is painful” that the Global North continues asking countries “to increase borrowing to build resilient infrastructure for something that we did not do”. UN secretary general António Guterres called for reforming the financial institutions and architecture, and the G20 declaration (with India clearly defining itself as the voice of the Global South) echoed the calls of the Bridgetown Initiative on debt and access. In the pandemic accord negotiations, the principle of common but differentiated responsibilities was put on the table. The paltry sum available for the Pandemic Fund combined with a complex application procedure still reflects the approaches of the systems that must be overcome. UNAIDS executive director Winnie Byanyima drew attention to the fact that Africa has made $79 billion in debt repayments in 2021 – but that the pandemic fund has only $3 billion to disperse.
There is therefore every reason why the UN and its organisations are rocked by political debates – the world is changing dramatically. This is where these debates must happen, in the only inclusive forum that enables them, including the WHO. This does not mean that the organisations are not fit for purpose: they are integral political platforms for reshaping the world. They must respond to this role with sound judgement. We cannot afford their demise, as happened with the League of Nations. All the African leaders who spoke at UNGA reiterated its importance to them – those leaders who did not come might want to keep this in mind. Multilateralism will continue to be a patchwork and very much more difficult over the next years.
The solutions will not come quickly. They will need to be bold, but they are worth fighting for.
