Health: A Political Choice – Building Resilience and Trust is a leading global health publication exploring how stronger systems, trusted institutions and effective leadership can underpin a healthier and more secure world. Produced with the support of the World Health Organization, it brings together influential voices from across government, international organisations, academia and industry. Edited by Ilona Kickbusch and John Kirton, the edition examines how resilience and trust can be embedded across health systems, from infrastructure and diplomacy to community engagement and innovation. With expert insights and real-world perspectives, it offers a timely guide for decision-makers seeking to strengthen global health in an era of growing uncertainty.
Health: A Political Choice
From Fragmentation to Integration
Edited by Ilona Kickbusch , Global Health Centre, Geneva and John Kirton , Global Governance Program, Toronto
Building Resilience and Trust Health: A Political Choice
1 INTRODUCTIONS
1.1 The economy of well-being Tedros Adhanom Ghebreyesus, director-general, World Health Organization p06 1.2 How to create trust in science: the responsibility of academic institutions Axel R Pries, president, World Health Summit p08 PROMOTED CONTENT Ensuring health policies transcend political cycles: a call for sustainable reform Michel Demaré, chair of the board, AstraZeneca p10 1.3 Health and well-being: fairness for all generations Achim Steiner, administrator, United Nations Development Programme p12 PROMOTED CONTENT Addressing health holistically requires promoting meaningful social connection Karen DeSalvo, chief health officer, and Monica Bharel, clinical specialist, Google p14 1.4 Rose Gana Fomban Leke, 2023 Virchow Prize laureate, Favour Amarachi Nwogu, secretary, Multilateral Initiative on Malaria Society, and Wilfred Mbacham, founder, Fobang Institutes for Innovations in Science and Technology p16 PROMOTED CONTENT Alleviating global health disparities among the older Health as a political choice: building resilience and trust
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Health: A Political Choice is an official publication of the Global Governance Project. The Global Governance Project is a joint initiative between GT Media , a publishing company based in London, the Global Governance Program, based at the University of Toronto, and the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva. The Global Governance Project provides a vital function for private and public sector organisations in support of their governance responsibilities. As a project it publishes content on how we can all demonstrate better collective governance, via independent platforms, for the world’s largest intergovernmental organisations, governments, NGOs, multilateral and bilateral summits, and the private sector’s leadership.
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population through healthspan science Mehmood Khan, CEO, Hevolution Foundation p18
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Health: A Political Choice
3 A NEW GLOBAL HEALTH ORDER 3.2 A view from the Global South Mansukh Mandaviya, union 3.4 G20 and G7 convergence key for a new
3.1 A healthier future in sight Katsunobu Kato, former minister of health, labour and welfare, Japan p24 PROMOTED CONTENT AI’s transformative potential to improve global health equity Karen DeSalvo, chief health officer, and Ivor Horn, chief health equity officer, Google p26
SPOTLIGHT ON FINANCING
global health order Hatice Beton, executive director, G20 and G7 Health and Development Partnership p32
minister of health and family welfare, India p28
A new financial platform Catharina Boehme, assistant director-general, External Relations and Governance, World
3.3 From crisis to partnership
3.5 The climate crisis is a health crisis
Health Organization, and Thomas Östros, vice president, European Investment Bank p36
Stella Kyriakides, European Commissioner for Health and Food Safety p30
Vanessa Kerry, WHO Special Envoy for Climate Change and Health p34
4
INTEGRATING ACTION FOR HEALTH AND WELL-BEING
4.2 The whole: greater than the sum of its parts Joy St John, executive director, Caribbean Public Health Agency p43 4.3 From dementia to ‘supermentia’ Vladimir Hachinski, Western University, and Mayowa Owolabi, University of Ibadan p46
PROMOTED CONTENT Gender equity is the backbone of global prosperity Kevin Ali, CEO and board member, Organon p48 4.4 Building integrated health systems saves lives Carolyn Bennett, member of parliament, Canada p50
4.1 Nothing about us without us Inger Ashing, CEO, Save the Children International p38
SPOTLIGHT ON WORKFORCE From a vicious cycle to
PROMOTED CONTENT Soaring drones: delivering a milestone in tackling healthcare disparities Maria Tereno, corporate vice president, culture
a virtuous cycle Interview with Pamela Cipriano, president, International Council of Nurses p52
and sustainability, Boehringer Ingelheim p40
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Health: A Political Choice – From Fragmentation to Integration
5 6 PLANETARY HEALTH
DIGITAL TRANSFORMATION OF HEALTH
5.1 Healthier
5.5 Lebanon: reform and sustainability Firass Abiad, minister of public health, Lebanon p64 PROMOTED CONTENT Innovation and equity: at the core of future pandemic responses Thomas Cueni, director-general, IFPMA p66 5.6 A new narrative of hope Omnia El Omrani, climate change and health junior policy fellow, Institute of Global Health Innovation, Imperial College London p68 5.7
6.1 Transformation supporting a shift from analogue to digital health systems Alain Labrique, director, Digital Health and Innovation, World Health Organization p74 PROMOTED CONTENT Alternative futures for digital health Jake Atkinson, STOPAIDS, Sara (Meg) Davis, Centre for Interdisciplinary Methodologies, University of Warwick, Ulla Jasper, Fondation Botnar, Maria Malomalo, Restless Development, and Sabina F Rashid, James P Grant School of Public Health, Brac University p76 6.2 A plague on health systems Anurag Agrawal, dean, Biosciences and Health Research, Trivedi School of Biosciences, Ashoka University p78 6.3 Seamless, simple and Görgens, lead, Digital Health Flagship Program, World Bank p80 speedy Marelize
PROMOTED CONTENT A more equitable future for health information Garth Graham, head, YouTube Health p82 6.4 Health data: everyone’s business Mathilde Forslund, executive director, Transform Health p84 6.5 Equity in eHealth: amplifying youth voices in mental health care Melissa Gasser, PhD candidate, University of Washington p86 6.6 Digitalising
environments: a requirement for better health and safety
Maria Neira, director, and Annette Prüss, unit head, policies and interventions, Health and Environment Department of Environment, Climate Change and Health World Health Organization p54 5.2 Biodiversity and health: from fragmentation to integration David Cooper, acting executive secretary, Secretariat of the Convention on Biological Diversity p56 PROMOTED CONTENT The call for a health taxonomy Interview with Dr Zhi Yang, chair, BVCF p58 5.3 Interview with Monique Eliot, director-general, World Organisation for Animal Health p60 5.4 In the face of future disasters Mami Mizutori, head, United Nations Office for Disaster Risk Reduction p62 From theory to practice
Slovenia’s healthcare system
Many for the price of one C James Hospedales, founder,
Interview with Kerstin Vesna Petrič, head, Office for Cooperation
EarthMedic and EarthNurse Foundation for Planetary Health p70 SPOTLIGHT ON AFRICA A new deal for African health security Jean Kaseya, CEO and director-general, Africa Centres for
with WHO, and Alenka Kolar, director-general, Directorate for the Digitalization in Healthcare, Ministry of Health Slovenia, and Hajdi Kosednar, eHealth Manager, Centre for Healthcare Informatics, Public Health Institute of Slovenia p88 6.7 New healthcare frontiers Maliha Hashmi, World Economic Forum Global Future Council Expert p90
Disease Control and Prevention p72
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Health: A Political Choice – From Fragmentation to Integration
7 8 PREPARING FOR A SAFER WORLD TOGETHER
INTEGRATING RESPONSES TO INEQUALITIES AND DISEASE BURDENS
7.1 A pact for global
7.5 Trust during pandemics: a critical determinant of successful response
pandemic readiness Karl Lauterbach, health minister, Federal Republic of Germany p92 7.2 Reshaping Ayoade Olatunbosun- Alakija, WHO Special Envoy for the Access to COVID-19 Tools Accelerator, and chair, Foundation for Innovative New Diagnostics p94 7.3 global health a testament to multilateralism M Chatib Basri, co-chair, Pandemic Fund p96 7.4 Tackling it together: for a unified pandemic response Precious Matsoso, co-chair, Intergovernmental The Pandemic Fund, Negotiating Body for the Pandemic Accord, and Elil Renganathan, professor of public health and policy, Sunway University p98
8.1 Health care away from home
PROMOTED CONTENT Tackling the global burden of cancer Markus Kosch, head of oncology, Europe and Canada, Daiichi Sankyo p116 8.5 The impact of globalisation on the health of at-risk populations Ernest C Madu, chair, Heart Institute of the Caribbean and HIC Heart Hospital p118 8.6
Sylvie Briand, director, Epidemic and Pandemic Preparedness and Prevention, and Sarah Hess, World Health Organization p100
Interview with Raouf Mazou, assistant high commissioner for operations, United Nations High Commission for Refugees p108 8.2 A social justice approach to health Gilbert F Houngbo, director-general, International Labour Organization p110 8.3 Defining the future of global health José Manuel Barroso, board chair, Gavi, and former president, European Commission p112 8.4 Struggling to heal: Egypt’s health initiatives in the face of health burdens Khaled Abdel Ghaffar, minister of health and population, Egypt p114
7.6 Health surveillance: the bedrock of health security Chikwe Ihekweazu, Samuel Mbuthia
and Mala Kumar, WHO Open Source Programme Office, WHO Hub for Pandemic and Epidemic Intelligence p102
A gender-equal health system Interview with Kolinda
7.7 A 100-day
Grabar-Kitarović and Joy Phumaphi, co-chairs, Global Preparedness Monitoring Board p120 8.7 Empowering communities worldwide: the Global Contraception Atlas Neil Datta, executive director, European Parliamentary Forum for Sexual and Reproductive Rights p122
mission Oyeronke Oyebanji, chief of staff for
policy and partnerships, and Frederik Kristensen, deputy CEO, Coalition for Epidemic Preparedness Innovations p104 SPOTLIGHT ON WELL-BEING Unlocking health for all Hans Henri P Kluge, director, World Health Organization’s Regional Office for Europe p106
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Health: A Political Choice – From Fragmentation to Integration
1.4 1
Health: a human right Since the World Health Organization was founded, human health has improved significantly – but progress in many areas has slowed or stalled, and this year represents an important opportunity to chart a new path forward and put people’s health first
T
By Tedros Adhanom Ghebreyesus, director-general,
he World Health Organization was founded 75 years ago, as countries were rebuilding
we fail to learn that lesson, we expose ourselves and future generations to the potentially devastating impacts of future pandemics on lives, livelihoods, societies and economies. That means investments in protecting health are also investments in social, economic and political stability and security. Countries spend vast sums preparing for the threat of a terrorist attack, but relatively little preparing for the attack of a virus, which can be far more damaging, and far more costly. GOVERNMENTS UNDER PRESSURE At a time when economies are stagnating, debt is rising and budgets are squeezed, governments are under pressure to tighten the purse strings. But now is exactly the right moment to make strategic investments in health – investments in human capital – that will pay dividends for decades to come in more healthy, productive, secure, equitable and sustainable societies. The best investments in health – and the most cost effective – are in primary health care. Many people think of primary health care as delivering essential health services at the local level, and it certainly includes that. But a primary health care approach goes beyond providing health services to include action to address the drivers of disease, and to empower people to take charge of their own health. It recognises that health does not start in hospitals or clinics, but in homes, schools, streets, workplaces and markets – in the air people breathe,
World Health Organization
after the collective trauma of World War Two. It was
against that backdrop that the authors of the WHO’s constitution affirmed both that health is a human right and that the health of all people is fundamental to peace and security. Since then, human health has improved significantly. Global life expectancy has increased from 46 to 73 years, with the greatest gains in the poorest countries. Smallpox has been eradicated, polio and Guinea worm disease are on the brink, and the epidemics of HIV, malaria and tuberculosis have been pushed back. In the past 20 years alone, smoking has fallen by a third, maternal mortality has fallen by a third and child mortality has more than halved. However, even before Covid-19 arrived, progress towards many health targets agreed by all in the Sustainable Development Goals had slowed or stalled, and the pandemic set us even further back. On top of the death and suffering it caused, Covid-19 severely disrupted health systems, roiled economies and caused immense social upheaval, while also fraying the fabric of multilateralism. One of the key lessons of Covid-19, therefore, is that a pandemic is so much more than a health crisis: when health is at risk, everything is at risk. If
6
“ Countries spend vast sums preparing for the threat of a terrorist attack, but relatively little preparing for the attack of a virus, which can be far more damaging, and far more costly” A DECISIVE YEAR FOR GLOBAL HEALTH
1.1
TEDROS ADHANOM GHEBREYESUS Tedros Adhanom Ghebreyesus was elected director-general of the World Health Organization in 2017 and re-elected for a second term in 2022. He was the first person from the WHO African Region to serve as WHO’s chief technical and administrative officer. He served as Ethiopia’s minister of foreign affairs from 2012 to 2016 and minister of health from 2005 to 2012. He was elected chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria Board in 2009, and previously chaired the Roll Back Malaria Partnership Board, and co-chaired the Partnership for Maternal, Newborn and Child Health Board. in which countries that are otherwise political and economic rivals can work together to build a common approach to common threats. Indeed, that is what countries are doing, in negotiating a new legally binding pandemic accord and amendments to the International Health Regulations, the instrument of international law that governs the global response to health emergencies. At this year’s United Nations General Assembly, countries also agreed on political declarations on pandemic preparedness and response, universal health coverage and tuberculosis. The negotiations are not always easy, and there remain areas of contention between countries, particularly concerning equitable access to health technologies. However, just as in 1948 when countries came together in the aftermath of the bloodiest war in history to establish the WHO, now countries must come together in the wake of the most severe health crisis in a century to chart a new path forward together. The challenges we face may be different, but the vision remains the same: health as a human right, and the foundation of peace and security. ▪ the food they eat and the conditions in which they live and work. Creating healthy populations is therefore not solely the task of ministries of health, but requires health-promoting policies in trade, commerce, education, energy, agriculture, urban planning, transport and more. The health challenges we face today have changed considerably since the WHO was founded in 1948. Non-communicable diseases now account for 70% of all deaths globally; obesity rates have skyrocketed; antimicrobial resistance threatens to unwind a century of medical progress; and air pollution and climate change are jeopardising the very habitability of the planet on which all life depends. These challenges have no regard for the lines humans draw on maps, nor for ideologies, religions, economic or military might, or for anything else that we use to divide ourselves from each other. The need for multilateral cooperation is therefore greater than ever, and so is the opportunity. At a time of polarisation, health is one of the few areas
X-TWITTER @DrTedros who.int
7 Health: A Political Choice – From Fragmentation to Integration
A DECISIVE YEAR FOR GLOBAL HEALTH 1.2
This year is a defining one for global health, as the world endeavours to tip the balance towards coordinated, strong, multilateral action and away from fragmentation. But progress so far has been disappointing – and time is running out to make the right political choices that will drive positive change Addressing the deficiencies of globalisation
healthy and sustainable world for the future if we establish a coordinated reaction – and transition from fragmentation to integration. For this change, 2023 is a ‘Defining Year for Global Health’ as reflected by the theme of this year’s World Health Summit. It is defining with respect to tilting the balance towards coordinated and strong multilateral action and away from fragmentation and national egoism. We must seize this chance and live up to our responsibility. This year, the 78th United Nations General Assembly focused on health, underlined by various high-level meetings in New York in September. Long-standing, yet pressing, issues such as universal health coverage, the fight against tuberculosis, as well as pandemic preparedness, prevention and response were covered. Yet the initial reactions to the draft declarations for these meetings were dominated by disappointment and frustration. Despite much anticipation, there appears to be little advance from the status quo. Underlying the disappointing progress is a phenomenon that may be referred to as a ‘globalisation mismatch’: science and industry operate effectively at the global scale, while political power is largely focused on a national level.
T he world is facing more and more truly global threats and challenges. As an example, Covid-19 did not respect national or regional boundaries, effectively making the entirety of humankind an infection reservoir and breeding ground. Similarly, the climate crisis endangers living conditions in all regions of the world. This year perhaps more than ever, people everywhere have experienced its devastating effects and its impact on health and well-being. Humanity is not passively suffering from different plagues and natural events – it has, in fact, caused or exacerbated many of these developments. This is reflected in the scientific discussion over the term ‘Anthropocene’, the proposed geological epoch characterised by humankind’s dominating force. We have drastically reduced living spaces for many species and significantly changed the composition of the atmosphere. The human domination of the biosphere has not been carried out systematically but results from increasing industrial, technological and scientific achievements and the fragmented actions of individuals and countries, according to their interests and motivations. The corollaries of human development are far-reaching in their scale and impact. We can only face these threats, mitigate the negative impacts of human-made changes, and secure a
By Axel R Pries and Frederike Sontag, World Health Summit
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Health: A Political Choice – From Fragmentation to Integration
Industry and science
BARRIERS TO COOPERATION The globalisation mismatch describes barriers to international cooperation on a political scale that do not exist in the same way in other domains such as scientific research and innovative technology. The globalisation mismatch and the lack of political power on an international, global level favour already powerful states, enterprises and individuals. This has ultimately led to inequality within and between countries, which in turn has reduced social cohesion as well as trust in political institutions. Most importantly, it has obstructed effective global responses to pressing global challenges in health, climate, pollution and migration. Governments still aim to protect cooperation seems to have a set limit. This is an understandable reaction considering national election processes and geopolitical tensions are making truly global cooperation impossible. Yet the deeply rooted mechanisms of the past cannot help us through the crises that these reflexes have themselves generated. As Einstein said: “You can’t solve problems with the same mindset that created them.” With climate-related crises happening regularly across the globe, there are no real alternatives to international cooperation. We need to strengthen international institutions to ensure solid, multilateral non-nationalist leadership in times of global challenges. In the health sector, a strong World Health Organization is needed to avoid fragmented responses to future health threats. national sovereignty while the strengthening of international At the World Health Summit in 2021, the Global Preparedness Monitoring Board launched its annual report, From Worlds Apart to a World Prepared. It warned of a “cycle of panic and neglect” and called for a level of ambition to match the global need. Two years later, these requests for change remain highly relevant and, to a large part, still not fulfilled. With regards to the climate crisis, governments seem immune even to entering the panic stage, regardless of how many climate activists are flocking to their doorsteps. We seem to be entering a phase of neglect regarding pandemic preparedness and corresponding international commitments. IMPROVING HEALTH WORLDWISE Fragmentation in global health is prevalent in governments, research and
Globalized approaches and power
THE GLOBALISATION MISMATCH
Governance
National interest and power Figure 1: The global spread of scientific knowledge and technological innovations is fast, supply chains span the world, and industry has global reach and power. At the same time, governance is mostly confined to the national level and international political bodies are weak.
aid programmes. Private foundations are trying to play an integral role in improving health worldwide. The number of global health actors with somewhat different missions all aiming to benefit health and well-being for all is countless. The integration of these efforts has fallen short. The goal of the World Health Summit is to overcome fragmentation, to bring together stakeholders from various sectors, including academia, politics, the private sector and civil society, and to stimulate new and coordinated approaches. It raises awareness of the urgency of such change and provides an opportunity for global health actors to interact and synergise in their different perspectives. This alone will not suffice to address the globalisation mismatch, which requires a fundamental change in political approaches. But such a change should be motivated by the equally fundamental change in the nature of challenges to humankind. It is not about who wins or how to help in cases of regional calamities. We must stand together in unprecedented ways to safeguard life on Earth in the way we know it and want to preserve for future generations. I am confident that this synergy will prove that health is a political choice. ▪ Acknowledgement: The support of Maeve Cook-Deegan in generating the manuscript is gratefully acknowledged.
AXEL RADLACH PRIES Axel Radlach Pries became president of the World Health Summit in 2021. He was the dean of Charité from 2015 to 2022, having been head of the Charité Institute for Physiology from 2001. He has chaired the Council for Basic Cardiovascular Science and the Congress Programme Committee basic section in the European Society of Cardiology, was president of the Biomedical Alliance in Europe and CEO of the Berlin Institute of Health. He has received the Malpighi Award, the Poiseuille Gold Medal and the Silver Medal of the European Society of Cardiology. X-TWITTER @WorldHealthSmt @ChariteBerlin worldhealthsummit.org charite.de
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Health: A Political Choice – From Fragmentation to Integration
1.3
DECISIVE YEAR FOR GLOBAL HEALTH
By Amina J Mohammed, deputy secretary-general, United Nations
E veryone has a right to health and medical care – a right enshrined in the Universal Declaration of Human Rights and the Constitution of the World Health Organization. Yet hundreds of millions of people, in rich countries as well as poor, do not have access to the care they need. This jeopardises their health, undermines their rights and deepens inequalities. And it makes it more difficult to meet the with costly, fragmented and poorly integrated care systems that fail to uphold their health and well-being. Such fragmentation can be fatal, leading to complications, duplications, and delayed or discontinued care. Even where health care is accessible, access can be fragile, as the Covid-19 pandemic illustrated. More than 90% of countries reported that the pandemic disrupted essential health services. Some 25 million children under the age of five missed out on routine immunisation. Each of us needs timely, affordable access to comprehensive, quality health care, staffed by people we trust. Accessibility of health care is vital to ensuring no one is left behind. That means integrating health care into other services and sectors, supported by systems and environments that promote health and well-being. Tuberculosis, diabetes and many other conditions are preventable through societal and environmental changes – improved hygiene, nutrition and air quality, for example. We need to recognise that we are not islands; our health is intertwined Sustainable Development Goals. Far too often, people are faced with the well-being of our planet and our societies. We need to create health systems that invest in managing disease as well as in promoting good physical, mental and social well-being, prioritising interventions that address major risk factors. We also need to redesign infrastructure and systems to promote health and social cohesion, ensuring they support everyone equally and respect our environment. Think of a mother, a nomad, in the deserts of the Sahel, who awakes in the night, alarmed by her baby’s high temperature. She needs good roads so
Health at the heart of sustainable development Millions of people around the world are being denied their human right to health and medical care. Only by placing universal health coverage at the core of sustainable development efforts can we truly ensure the health and well-being of all people – for our shared prosperity and for the planet that sustains us
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Health: A Political Choice – From Fragmentation to Integration
“ Universal health coverage embodies the world’s agreement on the need for quality health care for all, without discrimination or financial hardship”
that local transport can reach her and take her to a healthcare centre that is open all hours and where qualified, trusted staff, who understand her needs, will refer her to specialist care if necessary. Or think of a teenager, unable to cope with the stress of school and the effects of the Covid-19 pandemic. They need an education system that promotes health, understands their fears, and provides them with the information and support they need to stay active and healthy, including mental health services. Universal health coverage embodies the world’s agreement on the need for quality health care for all, without discrimination or financial hardship. It means that services are delivered in an integrated, people-centred way, close to where they live and work, in ways that respect their values, human rights, dignity and equality. REFOCUSING HEALTH SYSTEMS Refocusing national health systems on primary health care is the most equitable, effective and cost-efficient way to deliver on the promise of universal health coverage and health security. A health system that is founded on the principles of primary health care can better protect and serve communities by treating people when they are sick and helping to prevent diseases by addressing the external factors that affect health and well-being. Such a system is key to the long-term resilience of health systems – the fragility of which has been exposed by the Covid-19 pandemic. As the first point of contact between individuals, communities and national systems, for example, a PHC system can effectively control disease outbreaks through immunisation and prevention and maintain essential health and social care services when hospitals are overwhelmed. Strengthening resilience is critical to providing continued care, and to ensuring timely and effective responses to, and recovery from, shocks and crises. Focusing health systems on primary health care requires government and governance, backed by strong and aligned financing systems. Many continue to rely on external assistance to fund their health systems. This external assistance is still too often heavily earmarked to support specific diseases or interventions that drive fragmentation and separate delivery channels, making it difficult
for country decision makers to finance and deliver a universal package with comprehensive services. Even when external funds are moved ‘on budget’, fragmented fund flows will persist without specific efforts to improve coordination. We need international and national actors to unite on a common vision to avoid this. This September, three high-level meetings on health took place at the United Nations General Assembly, providing world leaders a unique opportunity to make progress on these issues: to bolster health systems to achieve universal health coverage, end tuberculosis, strengthen pandemic prevention, preparedness and response, and invigorate progress on SDG3 – to ensure healthy lives and well-being for all. This is a chance to elevate health to the highest political level, to generate clear political commitment, and align national and international actors. Governments must agree on ways forward to scale up progress on communicable diseases, address the rising burdens caused by non-communicable diseases and mental health, and the growing threats posed by climate change and antimicrobial resistance. Civil society, healthcare representatives and more of us can support them by raising our voices and sharing a common vision of people-centred, integrated health services for all. In all countries, a PHC approach can be critical to achieving that vision. Investing in a PHC approach is vital for the health and well-being of all people, for their prosperity, and for the planet that sustains us. ▪
AMINA J MOHAMMED Amina J Mohammed is deputy secretary- general of the United Nations and chair of the United Nations Sustainable Development Group. Previously she served as the minister of environment of Nigeria. She first joined the UN in 2012 as special adviser to Secretary-General Ban Ki-moon with the responsibility for post- 2015 development planning. In Nigeria, she served as an advocate for increasing access to education and other social services, and advised four successive presidents on poverty, public sector reform and sustainable development.
X-TWITTER @AminaJMohammed un.org/sg/en/dsg
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Health: A Political Choice – From Fragmentation to Integration
1.5
SOLIDARITY
An ‘off the shelf’ cure for fragmentation?
I n 2015, countries and communities joined hands to craft and agree on the 2030 Agenda for Sustainable Development, a historic plan of action for people and planet. Much progress has been made, including reducing poverty and child mortality. Yet life expectancy dropped between 2019 and 2021 in the wake of the Covid-19 pandemic, the first such drop since 1950. The pandemic has stalled, and even reversed, steady improvements in public health. At the current rate of progress, universal health coverage, a pathway to delivering on everyone’s right to health, remains beyond reach, with approximately two billion people facing the effects of “catastrophic or impoverishing health spending”. Just 15% of the Sustainable Development Goal targets are on track. HOW DID WE END UP WITH THE FUTURE WE HAVE? Consider the fact that taxpayers give fossil fuel companies $11 million in subsidies every minute – which are supercharging
human rights, the rule of law, gender equality and civic space. Today, another ‘disease’ afflicts our countries and institutions, sickening people and planet: a virus of fragmentation. The 2030 Agenda, with its globally shared promise to leave no one behind, represents the best, ‘off the shelf’ cure. BRIDGING COUNTRIES Time, political will, financing and action remain in short supply. In this time of polycrisis, with global threats growing in number and complexity, we must think and act differently. As United Nations secretary-general António Guterres says, we must prepare for the health threats to come – from the next pandemic to climate threats – to prevent them where we can and respond fast and effectively where we cannot. The World Health Summit and the SDG Summit in 2023 represent new opportunities to secure the rights and well-being of all and protect our planet. That includes extending universal health
The virus of fragmentation is afflicting our countries and institutions, sickening people and planet – but, with its globally shared promise to leave no one behind, the 2030 Agenda offers an ‘off the shelf’ cure
By Achim Steiner, administrator, United Nations Development Programme
the climate emergency – even as droughts, floods, fires, hurricanes and heatwaves are harming and destroying the livelihoods of millions of people. Violent conflicts are at their highest levels since the Second World War. We are seeing pushback on
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Health: A Political Choice – From Fragmentation to Integration
coverage and pandemic preparedness and response based on a human security approach so we can realise resilient health systems that flexibly tackle health emergencies and multiple threats to health. We can also bring a globally networked innovation and access ecosystem for medical countermeasures to life by committing to sharing solutions such as vaccines and other health technologies as global public goods. This would save lives and restore trust in our global systems. We must also reverse other areas of fragmentation affecting health and well-being. The Paris Agreement is a public health agreement as much as it is one of climate action. By delivering on it, we can advance the right to a clean, healthy and sustainable environment together with people’s health and well-being. RETIRING ‘TRADE-OFFS’ The 2030 Agenda is also prompting a re-think of the metrics needed to secure the future of people and planet. That means looking beyond gross domestic product to leverage synergies across sectors. For instance, a just energy transition would dramatically reduce harmful greenhouse gas emissions while advancing social justice, human rights, gender equality, health, education, jobs and livelihoods. Smart use of data and analytics are key to scaling the integrated solutions to responding to the multidimensional aspects of health and well-being. The UN Development Programme’s ‘SDG Push’ analysis shows that it is still possible for countries to outperform their pre-Covid development projections by investing across core SDG ‘drivers’ including health, social protection, a green transition, digitalisation and governance. INSTITUTIONS FOR THE 21ST CENTURY The UN system, as our primary global anchor to promote peace, security, and development, must also evolve. Secretary-General Guterres has an ambitious plan for a revitalised UN through the Our Common Agenda report, and a spirit of multilateral collaboration is being nurtured through initiatives such as the SDG3 Global Action Plan. This has paved the way for the UN Comprehensive Response to Covid-19, which integrated health, development and humanitarian support through the pandemic. There is much more to be done on pandemic preparedness and response, but the UN and its many partners are now better equipped to respond to complex health emergencies. Efforts to stay and deliver in Afghanistan, Sudan, Syria, Ukraine and beyond demonstrate this fact. Global health governance is evolving in other ways. Gavi, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President’s Emergency Plan for AIDS Relief are ACHIM STEINER Achim Steiner has been the administrator of the United Nations Development Programme since 2017. He is also the vice-chair of the UN Sustainable Development Group, which unites 40 entities of the UN system that work to support sustainable development. Prior to joining UNDP, he was director of the Oxford Martin School and Professorial Fellow of Balliol College, University of Oxford. He led the UN Environment Programme (2006–2016) and was also director-general of the United Nations Office at Nairobi. He previously held other notable positions including director-general of the International Union for the Conservation of Nature and secretary-general of the World Commission on Dams. X-TWITTER @ASteiner undp.org
integrating their disease-specific responses with broader efforts to strengthen health systems and prepare for pandemics. The International Health Regulations are undergoing long-awaited amendments; a new pandemic accord is in the works; and other strong proposals have been put forth to make Covid-19 the last pandemic of its kind. The mRNA vaccine technology transfer hub in South Africa initiated by the World Health Organization is a clear demonstration of how developing countries are becoming a nucleus for the solutions that our global community now needs. Whether this all ultimately makes the world safer depends on the same essential elements: political will at all levels for multisectoral and timely responses, an empowered WHO and a shared commitment to equity. As ever, finance is pivotal. That involves reforming the international financial architecture and directly tackling the global debt crisis at a time when many developing countries are spending, on average, 1.4 times more simply to service their debt than they allocate to health care. These shifts could unlock hundreds of billions of dollars to invest in health, climate and all 17 SDGs. SOLIDARITY OVER SEPARATION The estimated 24 million excess deaths and counting due to Covid-19 should not be the jolt we need to take pandemic preparedness seriously. Nor should countries and communities be locked into a never-ending cycle of polycrisis to grasp the importance of the SDGs. In a world riven by the impacts of conflicts, geopolitical tensions and the climate emergency, we have a clear way out. The 2030 Agenda represents one of the only platforms that all countries still agree on for navigating through this sea of uncertainty. We must act upon it as our global community’s best hope to defeat the virus of fragmentation. Solidarity can win over separation. ▪
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Health: A Political Choice – From Fragmentation to Integration
1.5 2
The patchwork of global health policymaking
T he 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. 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
By Ilona Kickbusch founding director, Global Health Centre, Graduate Institute of International and Development Studies
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
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ILONA KICKBUSCH Ilona Kickbusch is the founding director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, Switzerland. She served on a panel of
independent experts to assess the World Health Organization’s response to the Ebola outbreak and is a member of the Global Preparedness Monitoring Board. She previously had a distinguished career with the WHO and Yale University, and has published widely on global health governance and global health diplomacy. She is a member of the WHO Council on the Economics of Health For All. She is co-editor of, most recently, Health: A Political Choice – Investing in Health For All . X-TWITTER @ IlonaKickbusch ilonakickbusch.com
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. ▪
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Health: A Political Choice – From Fragmentation to Integration
2.2
EDITORS’ INTRODUCTIONS
Integrating global health governance for a fragmented world
As interconnected crises loom ahead that threaten our physical, mental and social well-being, the world urgently needs global health governance to replace our existing fragmented systems
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HEALTH: A POLITICAL CHOICE Health: A Political Choice – From Fragmentation to Integration
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