Threats to the foundations of global health

Amid calls for reform and actions that restrict the World Health Organization, Ilona Kickbusch, co-chair, UHC2030, and founding director, Global Health Centre, Graduate Institute of International and Development Studies in Geneva, says it is critical that institutions do not fall prey to geopolitical posturing and conflicts

There was initially great delight in the global health world when global health became part of the deliberations of the G7 and the G20. Not only were meetings of ministers of health held regularly by all hosts, but health issues also made their way into the leaders’ declarations. Countries used their presidency to boost global health – most recently in 2019 when France’s Emmanuel Macron, the host of the G7 summit that year, pushed for replenishing the Global Fund to Fight AIDS, Tuberculosis and Malaria. Health security issues including anti-microbial resistance were always on the agenda. Indeed, during Germany’s 2017 G20 presidency health ministers held a pandemic preparedness and response simulation to increase awareness of the potential pandemic threat. A new important dimension was added to global health governance.

Politicisation of the pandemic

Initially, it seemed promising that the G7 and the G20 had developed a higher awareness of health issues and took them beyond the health sector. Health was high on the political agenda. But the G7 and G20 always referred back to the World Health Organization and the United Nations for implementation. Japan’s G20 presidency in 2019 even organised a joint meeting of health and finance ministers to highlight the need to invest in health and universal health coverage, and later took the results to the High Level Meeting on UHC at the United Nations.

In 2020, the extraordinary politicisation of the COVID-19 pandemic is creating a backlash. It has been used by some members to attack the United Nations and its specialised organisations.

In the first instance, the United States is no longer willing to sign communiqués that express explicit support for the WHO, as President Donald Trump decided to blame it for the COVID-19 pandemic. The United States has also not joined the Access to COVID-19 Tools Accelerator, a global collaboration to accelerate development, production and equitable access to diagnostics, therapeutics and vaccines that includes all the other G7 members including the European Commission. They have all aligned with the WHO’s call for solidarity.

Reforms and restrictions

Although the WHO and its many partners are working flat out to fight the pandemic and raise funds at the same time, in the spring the United States presented its G7 partners with a list of WHO reforms to be carried out following on from the pandemic. The proposals focus mainly on the organisation’s independence and on transparency, exactly those issues that a key group of WHO member states have been keen to restrict. One long-standing criticism of the International Health Regulations – which the WHO must follow – has been that it has “no teeth”. Anyone working at the WHO would be thrilled if member states strengthened the independence of the WHO and its work. It is an unproven assumption, however, that the WHO director-general and the emergency committee, which advises when or whether to declare a public health emergency of international concern, were not independent in their decision-making. It does show the weaknesses of the concept of a public health emergency of international concern – which does not allow for intermediary warnings.

Compared to the constant noise about the WHO coming from the White House, these proposals sound sensible. They reflect ideas put forward by academics, member states and many commentators for years. Yes, they should be debated, but several points need to be considered first: the most important thing now is to work together to beat the virus; any evaluation at a moment when the pandemic response is so highly politicised would be counterproductive; and the WHO’s members already have review and oversight processes – the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme, the Review Committee on the Role of the International Health Regulations and the Global Preparedness Monitoring Board.

The most important issue, however, is that the proposals the United States presented to the G7 and that have now been revised based on the G7 discussion should be taken to the WHO’s governing bodies of member states: the Executive Board and the World Health Assembly. As the document to the G7 said, “the US is still a member state of the WHO and an active member of the WHO’s executive board”. The G7 and the G20 need to take positions on their support of multilateralism and the WHO – as they did in initial statements at the beginning of the crisis. They can play a key role in productive, forward-looking reforms based on lessons learned during COVID-19. One key lesson, of course, is that no matter how well prepared a country is for a pandemic, the final outcome will depend on the political decisions taken. And no matter how an international organisation like WHO responds, if it becomes a proxy for a geopolitical conflict its work is significantly impaired. The G7 and the G20 must address these political issues – because countries depend on one another and the WHO in a pandemic.

The critical warning

This is the critical warning: it is essential that major health challenges are taken to the G7 and G20, but those institutions must not fall prey to geopolitical posturing and conflicts – G7 and G20 members should be adamant that they will not accept this. They must also make clear that G7 and G20 members fully respect the constitution, governance and decision-making processes of the WHO. This means that decisions are taken by 194 sovereign member states after negotiations and consensus-finding processes. UN-based health diplomacy, which includes most of the world’s countries, cannot be replaced by highly politicised club diplomacy. If we go down that road, it would significantly weaken global health governance and endanger global health.