Global Health: G20 to the Rescue?

Global health continues to make headlines with cholera outbreaks in natural disaster zones such as Haiti and Pakistan and the flu season hitting Europe and North America. At the same time, a succession of disappointing news stories has hit the global health community in the past weeks. In September, the United Nations' report on progress toward achieving the Millennium Development Goals (MDGs) set out the immense challenges involved in meeting the health-related goals by 2015, especially on child and maternal health. In October, external pagepledgescall_made made to the replenishment summit of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) fell short of the target, as industrialized countries hesitated in the face of the financial crisis. And hopes that the Group of 20 (G20), a relatively new global governance body, would prioritize health as the G8 had previously done were dashed when it recently met in South Korea.

Health threats: crossing borders, transcending jurisdictions

Global health encompasses a broad range of foreign policy and diplomatic concerns, from trade and economics, to the environment, security and international development. As a consequence of the multi-faceted nature of this challenge, the system of global health governance has grown increasingly complex in the last decades. States, formerly the primary point of contact for health threats, often do not have the resources, capability or authority to adequately respond to global health challenges. New bodies such as the Global Fund and external pageUNITAIDcall_made have been created in addition to the WHO, and other institutions such as the World Trade Organization (WTO), now a major force in trade-related health issues, particularly medical intellectual property rights. The UN Security Council, which addressed HIV/AIDS in external pageUN Resolution 1308call_made, has also become involved in health-related issues. Moreover, non-governmental actors and public-private partnerships have established themselves as important parts of the global health architecture, as healthcare participants, advocates and funders. The Bill and Melinda Gates Foundation works across multiple fields and now allocates over external page$1.8 billioncall_made to global health initiatives annually.

At the same time, groups and organizations such as the Gates Foundation expose the most serious weakness of the global health governance system: its lack of sustainable funding. The Gates Foundation is one of the foremost examples of a newcomer to the global health architecture that has subsequently become indispensible - an inevitable consequence of the massive resources at its disposal. A generous contributor to the Global Fund, the Gates foundation is also heavily involved (as both financer and partner) in a whole host of global health initiatives, most of which are 'vertical' single-disease oriented programs. Although the scale of Gates' funding could be seen as both the cause and consequence of state disengagement in global health, it merely serves to highlight the lack of sustainable resources available for global health efforts.

In terms of state responses, the G8 is the flagship success story of a body which has addressed global health at the highest political level, issuing recommendations and pledging large sums of financial resources. However, the fulfillment of G8 promises such as those made in Gleneagles in 2005, with a few exceptions, has been dismal. Many have also been critical of its model which rests on the changing priorities of an elite club of rich nations that excludes both non-state organizations and the majority of those nations that face the most serious health and disease threats.

The MDG review also highlighted a dangerous lack of coordination and the absence of a coherent systemic approach to health and development issues. The coordination issue in particular has become increasingly problematic as the range of actors involved in global health governance has expanded, prompting a plethora of attempts to harmonize programs, but few tangible improvements in terms of delivering coordinated governance in the health arena. Given the need to strike a balance between tackling urgent health threats and strengthening health systems in general, it is important to ask how global health should be steered in order to most effectively address the wide range of health-related problems in the international arena.

The promise of the G20

For many, the emergence of the G20 appeared to offer both a more legitimate forum for debate and the possibility of gaining access to sustainable financial resources. More inclusive than the G8, the group counts among its members emerging economies with large populations; together it represents approximately external page90 percent of global gross national productcall_made. However, the G20 differs from the G8 inasmuch as it was originally a gathering of finance ministers and heads of central banks, brought together to discuss the world's financial order. Its initial success and subsequent growth in prominence was due to its effective, coordinated approach to global economic challenges.

Although heads of state also meet at G20 summits, the group seems to have shied away from many issues previously discussed at G8 meetings, particularly those related to health and development (see external pageSeoul Communiquécall_made), despite the creation of a Working Group on Development. Although the G20 could engage a multitude of actors and offer avenues for more south-south collaboration, pushing the group to consider health and development issues risks creating internal tensions, since some members insist on the purely economic mission of the G20.

Given the lack of interest shown by the G20 so far, how optimistic can we be about the body's future impact on global health? Despite the rise of non-state and private actors in this field, states will remain central to global health efforts. As a representative, multilateral vehicle for global policy coordination, the G20 could become active in coordinating and fundraising for global health efforts precisely because it can effectively pool state resources. It can also keep global health firmly on the high-level political agenda.

All in all, there seem to be grounds for hope. Global health is more visible than it ever was, both through its links with other global challenges and as a stand-alone issue. In the 2007 external pageOslo Declarationcall_made, seven ministers of foreign affairs insisted on the importance of health for other policy fields, notably security and economic stability. It provoked interest among the richest nations as well as emerging economies but has struggled to stimulate coordinated action, to transform the profile of global health concerns or to generate extra funding.

A fundamental reform of the overly complex global health architecture may be an almost impossible task - the number of actors and vested interests is simply too large. But global coordination of health initiatives could and should be made more effective. In order to bring global health to the forefront of global policymaking, we need to collect a body of evidence that shows how health issues connect to economic growth and foreign policy. Although issues such as pandemics clearly deserve to be highlighted in their own right, informing policymakers of how their vital interests are bound up with the effective global governance of health threats will make current efforts sustainable and much more effective.