Abstract
With Indonesia responsible for the G20 presidency in 2022, India (2023), and Brazil (2024), the chance to forge a common agenda, shaped by emerging economies should not be underestimated. All three were severely affected by the pandemic, hence a focus on pandemic preparedness & response are in the countries’ best interest.
An Indian G20 presidency could through several scenarios accomplish to inject more faith in the current global health system that is currently dominated by the debates surrounding IP-rights and health equity. While these are generally important to address, there are other promising pathways worth exploring.
These include but are not limited to establishing a direct link between the newly adopted Pandemic Fund hosted at the World Bank and any future pandemic instrument/treaty. Furthermore, to support the African Union’s vaccine development by working towards more procurement from African manufacturers and to strongly promote pandemic simulations within the G20.
1. The Challenge
Notwithstanding geopolitical differences, the G20 have accomplished to stitch together a joint communiqué during their meeting in Bali, Indonesia. This is remarkable given the diverging views on fundamental matters such as state sovereignty, rules-based international order or evidence-based communication. Particularly, the launch of the so-called financial intermediary fund for pandemic and epidemic preparedness that is hosted by the World Bank and equipped with technical expertise coming from the World Health Organisation (WHO) will certainly be one of the cornerstones of the G20’s success stories last year.
It is now up to India under its theme “One Earth, One Family, One Future” to provide a certain degree of continuity, especially with regards to Global Health. According to its mandate, India should naturally be aware of the constraints and limits of its presidency, meaning to take into account the profound challenges (war in Ukraine, South China Sea, Taiwan) that loom over the G20’s ability to address common challenges.[i] Indonesia has provided excellent leadership and diplomatic skills in the area of Global Health and consequently left its mark to which India and the bloc will now be measured against.
2. The G20’s Role
A continued engagement in Global Health could facilitate to underscore the G20 as a rather effective global governance forum. The G20 countries host 80% of world GDP, 75% of global trade and 60% of the world's population and most of all pharmaceutical companies are within G20 member states’ boundaries. The G20 offers a much-needed dialogue platform, where developing and industrialized countries could meet on equal footing. India should position itself as an advocate for Global South countries’ demands and help to re-instate trust after the experiences from the Covid-19-Pandemic with regards to vaccine equity which have taken a major toll on multilateral relations and continue to loom over current global health negotiations. While this is certainly a noble intention India could bring into the halls of G20 as a “broker”, the paper goes beyond India’s role and focuses more on the G20 mechanisms and levers to advance Global Health Security.
As the world is transitioning now from the experiences of Covid-19 and trying to draw the “right lessons” to be put into practice in the near future, it is therefore surprising that global health does not seem to occupy a more prominent role within India’s G20 presidency when for instance looking at previous presidencies’ and their health agendas or when comparing the set-up of the Task Forces under the T20 process. Take Indonesia for example that attached greatest importance to Global Health Security, making Health one of its three main focal points.[ii] Deriving from that, one of the Task Forces within its T20 process was labelled “Global Health Security and COVID-19”.
Global Health is a subject that concerns all 20 member states and furthermore every corner of the world as seen with recent infectious diseases such as Covid-19 and the Mpox. Hence Global Health offers a starting point where to look at when confidence-building measures between states are of utmost importance and desperately needed, as there should naturally be not that much disagreement.
Improving national healthcare systems, delivering health outcomes for their citizens and avoiding the next global health crisis are within states’ best interests. It will therefore be India’s task to “recognise the realities of the post-pandemic world” and to put the marginalised/neglected sectors on top of its agenda.[iii] This would certainly encompass supporting an exhausted healthcare workforce and to better equip national healthcare systems in general (staffing, financial resources, technology) to foster its resilience.
A new understanding of health as a driver of economic development, for social well-being and as an overall key industry has undoubtedly emerged.[iv] Health has not only become a tool of partnership building that the European Union for instance expresses via its Global Health Strategy but countries pro-actively demand more technical cooperation between their respective Centres for Disease Prevention and Control or their Medical Agencies (and extendedly in pandemic simulations). Likewise, China and India have engaged in “vaccine diplomacy” to assist countries in their effort to protect populations against the cataclysmic effects of the pandemic. Putting an emphasis on Health as a mutual beneficial process for countries – within the G20 and beyond - is considered a way forward. Health could emerge as a soft power tool actively pursued by the G20 member states.
With Indonesia being in charge of the G20 presidency in 2022, India in 2023 and Brazil in 2024 (Troika), the chance and potential to forge a common agenda, shaped by emerging economies should not be overlooked. All three were severely affected by the pandemic, hence it should be in their best interest to keep focusing on matters relating to pandemic preparedness & response and to restore faith into the global health system.
Three years after the novel Sars-Cov-II-Virus was first announced to be a pandemic by the WHO on March 11, renewed calls for global collaboration have emerged.[v] Former UN Secretary-General Ban-Ki Moon said “[t]he great tragedy of the COVID-19 pandemic has been the failure of multilateralism and the absence of solidarity between the Global North and the Global South […]. We need a return to genuine cooperation between nations in our preparation and response to global threats.”[vi]
3. Recommendations to the G20
An Indian G20 presidency could through several scenarios accomplish to inject more faith and confidence in the current global health system that is currently dominated by the debates surrounding Intellectual Property (IP)-rights and health equity. While these are important to address, especially in the light of new pandemics, it should not distract from the fact that there are other promising pathways worth exploring.
(I) Linking the Pandemic Fund to any future Pandemic Instrument
Addressing some of the existing funding gaps and to put pandemic preparedness at the centre of political action, the Financial Intermediary Fund (FIF) for pandemic prevention, preparedness, and response (PPR) based at the World Bank and equipped with technical support from the WHO was established in 2022. In particular, the Pandemic Fund aims to strengthen PPR capacities (zoonoses surveillance, laboratories, emergency communication, coordination and management) in low- and middle-income countries (LMICs) and as aforementioned intends to close critical gaps through investments and technical support at national, regional and global levels.[vii] Specifically, an extension and development of local drug production is aimed to be achieved via the FIF. That said, ensuring a continued support to the fund at the World Bank would support local manufacturing capabilities in LMICs. Arguably the G20-sponsored FIF at the World Bank provides an essential tool, but cannot serve as a panacea for global equity in terms of resource allocation, manufacturing capabilities and access to scarce medicine.
The Pandemic Fund already received over 600 early expressions of interest from countries, regional bodies and global health organisations. Reports suggest that the requests are totaling more than $5.5 billion from a fund that was initially endowed with only $300M to spend.[viii] The Pandemic Fund was mainly developed by Italy and Indonesia under their respective G20 leadership. Hence being mainly a product borne by the G20, it is also up to the G20 to safeguard the pandemic fund’s inclusivity and make sure the fund does not create redundancies with existing structures or sideline important instruments such as the Contingency Fund for Emergencies (CEF). Resources within the CEF can be deployed within 24 hours to rapidly react to disease outbreaks and health emergencies.[ix] Both the FIF and CEF are dependent on member states’ contributions and while the FIF due to its recent inception and focus on pandemic preparedness is receiving much more attention, it may be indeed prioritized considering ongoing budget constraints’ especially in richer countries. As we have seen time and again, the Global Health System comes up with new actors that are here to stay, initially tapping into a niche and later-on expanding their core mandate. And at the same time, it resembles more of a marketplace where the organisations compete for limited resources to fill up their replenishment cycles.[x] While not questioning the importance of the pandemic fund, it is then the G20’s responsibility to secure the funds acceptance and embed it into the wider scope of Global Health.
Though, we still miss a direct reference between the FIF and ongoing negotiations surrounding the International Health Regulations (IHR) or the Pandemic Treaty. Especially the latter, originally titled as the “WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response” in itself entails the notion of pandemic preparedness. The current “draft” of the pandemic treaty that is currently negotiated by the member states does neither make a clear nor an implicit link to the pandemic fund. This is a major shortcoming, given that such a far-reaching document may be adopted by the World Health Assembly (WHA) in 2024. It is still to be determined, whether such a new treaty will incorporate a legal definition of a pandemic or replacing a Public Health Emergency of International Concern (PHEIC) altogether. But if it did, then there is a need to directly incorporate the fund in the pandemic actions, response and recovery.
Making a clear reference between the pandemic treaty and the pandemic fund would also allow to re-center the global health decisions/mandate back to Geneva. With the UN High-Level-Meetings on Universal Health Coverage (UHC), Tuberculosis and the Pandemic Summit are all to take place in New York and the Pandemic Fund hosted by the World Bank in Washington D.C., it seems as the political and financial decisions regarding Global Health are piecemeal occurring on US soil - arguably at the expense of WHO’s central leadership role. Like the former G20 presidencies, India should also work towards strengthening a Global Health Architecture with the WHO at its centre. We are reminded that the WHO with its decision-making body, the World Health Assembly, hosts all 194 member states and is the most inclusive forum within the Global Health System that should be uphold.
II) Creating Interlinkages between various multilateral flora
Heralded by Gavi, the Vaccine Alliance, alongside other partners such as the G7 Development Ministers, African Countries, international partners such as development financial institutions and the private sector, the common target set out was to support sustainable African manufacturing capacity. For that matter, Gavi has transformed its approach to procure more of its vaccines directly from African manufacturers and hence to assist the AU in its goal to produce and supply more than 60% of its vaccine doses on the continent by 2040 (benchmark: currently it supplies only 1%).[xi] Taking into account Gavi’s role as the single largest buyer of vaccines in the world, this could have far-reaching impact and spur local vaccine manufacturing. Instead of purely focusing on the price tag in their procurement decisions, Gavi will now also consider supply chain security and geographical diversity. Such an approach, initiated by the Vaccine Alliance, could serve as a blueprint for other international organizations such as UNICEF, which are as well responsible for buying and distributing vaccine doses in Africa and beyond. Higher prices may be laid off if countries are committing upfront to vaccines which would enable “predictable pooled procurement volumes”, as the strategy emphasises.[xii] Considering most of the voluntary contributions from member states or philanthropic organisations to the WHO are more often than not earmarked, hence to be used for a specific purpose, this could be now diverted to invest in existing capabilities and infrastructure in Africa.
Since the G7 Development Ministers were evidently part of spearheading an African-led manufacturing initiative, this approach could be further picked up and developed by the G20 to increase its visibility and feasibility. G7-initiatives often run the risk of easily being dismissed as purely representing Western interests, hence to cater for its own needs (pertaining the status quo or disproportionately favouring G7). A backing by the entire G20 group could secure more “buy-in” from states outside this group. The extended invitation to the African Union (AU) would furthermore help the cause.
This year provides ample opportunities to build a nexus between the G20 and UN-led processes and the institutions itself, such as the aforementioned UN High-level meetings. A frequent exchange between the G20 and the UN is considered vital (e.g. by inviting UN and WHO representatives to G20 meetings, preparational meetings between senior diplomats and state officials, working group meetings as in the joint finance-health group). Dr. Tedros, Director-General of the WHO, has for instance joined the G20 summit last year in Bali.
III) Pandemic Simulation within the G20
Under Germany’s G7 presidency last year, the G7 carried out a pandemic simulation scenario of a smallpox pandemic triggered by a leopard bite – parts of the result were presented at the World Health Summit 2022. We need to be constantly reminded that the next pandemic is not a question of if, but when – hence updating countries pandemic plans and simulating a joint response within the group is recommendable, especially given the weight of the G20.
A joint pandemic exercise should be an option on the agenda (for instance during the Health Ministers’ Meeting in August 2023). For the G7, the pandemic simulation was part of a larger agreement, a so-called “Pact for Pandemic Readiness” to be able to identify pandemic outbreaks faster and to guarantee a more effective response by strengthening early warning systems for effective pandemic preparedness.[xiii] The G7-Pact for Pandemic Readiness under the G7 concluded that more “experts are [to be] educated and trained to join [global] networks to detect and contain outbreaks early”, embedded in the WHO Hub for Pandemic and Epidemic Intelligence that serves as a hub node for data analysis.[xiv] More so, it aims to foster “a network for pandemic readiness with regional and national nodes based in the Global North and Global South”. Later in 2022, the G7 had published a roadmap for practical cooperation and to monitor progress on the Pact.[xv]
While it may have been relatively easy for the Berlin-based WHO-Hub for Pandemic and Epidemic Intelligence to act as a co-facilitator during last year’s Health Ministers’ Meeting in Germany, the hub as a part of the WHO Health Emergencies Programme can resort to WHO’s vast network of more than 150 countries, six Regional Offices, and its Geneva Headquarters. Hence a pandemic simulation exercise is not bound by specific place and can therefore be undertaken by G20 Health Ministers in India later this year, subject to political will. According to the WHO Hub, the discussions were embedded in a near-future scenario of a severe outbreak of an unknown disease that spreads rapidly to many parts of the world. Three overarching themes were addressed “collaborative surveillance, coordinated response, and preparedness” and Health Ministers had to answer a set of question (e.g. which actions will you take in the light of a global outbreak of a pandemic if you had to prioritise two out of four). The pandemic simulation tested Health Ministers’ decision-making during a pandemic as well as their ability to manage multiple threats at the same time as more information / data was gathered by the authorities.[xvi]
Emergency Preparedness simulation exercises are also part of longer series of programmes established by the John Hopkins Center for Health Security. In 2019 they created a fictional scenario (that very much resembled the later-on Covid-19-Pandemic) of a disease outbreak in pig farms in Brazil to educate senior staff in various administrations and industries. The design & implementation of such scenarios depends very much on a compelling narrative and underlying real-world dilemmas. The exercise consisted of pre-recorded news broadcasts, live “staff” briefings, and moderated discussions on specific topics. In different segments, the “players” were discussing “medical countermeasures”, “trade and travel”, “finance”, “communications / misinformation” issues.[xvii]
Pandemic plans need to be constantly re-evaluated and exercised, preparedness gaps closed and the results then integrated into the updated plans. Within that frame, the G20 should also discuss the topic of global surveillance (data-sharing and genome-sequencing) and emphasise the need for global cooperation. The G7 Pact for Pandemic Readiness and its Roadmap for Implementation fledge out two pillars on (1) collaborative surveillance and (2) predictable rapid response that could serve as blueprints for a deeper G20 engagement while not compromising WHO’s authority. The Pact is meant to support the existing International Health Regulations and should also not duplicate a potential pandemic accord.
Past mistakes, such as virtually isolating South Africa after it sequenced and shared the Omicron Strain of the Virus for the first time, must be avoided in the future. The cycle of “panic and neglect” needs to be broken. A (regular) pandemic simulation serves a helpful reminder in that regard.
Sources:
[i] Samir Saran, and Jhanvi, Tripathi, “What will India’s G20 presidency focus on?”, ORF Online, July 5, 2023.
[ii] Throughout the years, Global Health has experienced a steady elevation in G20 presidency’s programmes. The establishment of a regular Joint Finance-Health Task Force (2021) serves as another indicator.
See also: Sanjay M. Pattanshetty, Aniruddha Inamdar, and Helmut Brand, “Global Health Governance in an Uncertain World: A Proposed Framework for the G20,” ORF Issue Brief No. 608, January, 2023.
[iii] Samir Saran, and Jhanvi Tripathi, “What will India’s G20 presidency focus on?”, ORF Online, July 5, 2023.
[iv] Moritz Fink, “Europa als Globaler Gesundheitsakteur – mit Gesundheitspolitik zu neuen Partnerschaften“, Konrad-Adenauer-Stiftung, November 10, 2022.
[v] The World Health Organisation has officially declared an end to the “Public Health Emergency of International Concern” for Covid-19 in early May. World Health Organisation, “Statement on the fifteenth meeting of the IHR (2005) Emergency Committee on the COVID-19 pandemic”, May 05, 2023.
[vi] People’s Vaccine Alliance, “World leaders say Never Again to vaccine inequity”, March 11, 2023.
[vii] World Bank Group, “Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response”, November 13, 2022.
[viii] Jennifer Rigby, “Pandemic Fund vastly oversubscribed, more money needed”, Reuters Online, March 7, 2023.
[ix] World Health Organisation, “Contingency Fund for Emergencies”, 2023.
[x] Ilona Kickbusch, “The Politics of Global Health and the WHO“, Panorama: Insights into Asian and European Affairs 1 (2022): 27-48.
[xi] Kerry Cullinan, “Gavi Undertakes To Change Vaccine Procurement To Support New African Manufacturers”, Health Policy Watch, November 03, 2022.
[xii] Gavi, the Vaccine Alliance, “Gavi Expanding Sustainable Vaccine Manufacturing in Africa”, 2022.
[xiii] Global Health Hub Germany, “Results of the G7 Health Ministers’ Meeting in Berlin, 19–20 May 2022”, May 30, 2022.
[xiv] Federal Ministry of Health Germany, “G7 Pact for Pandemic Readiness Concept Note”, May 20, 2022.
[xv] Federal Government of Germany, “Roadmap for Practical Cooperation to advance the G7 Pact for Pandemic Readiness”, December 13, 2022.
[xvi] WHO Hub for Pandemic and Epidemic Intelligence, “Pandemic and Epidemic Intelligence”, June 15, 2022.
[xvii] John Hopkins Center for Health Security, “Tabletop Exercise 201”, October 18, 2019.