G20 and Global Health Governance

In order to handle public health threats and the dysfunctional global health system, and maintain organizational vitality, the G20 has been actively engaged in global health governance on setting agendas, building financing mechanisms, and working with other multilateral institutions, but it has also faced challenges such as different policy priorities among its members and the lack of monitoring mechanisms.

In recent years, global health governance has been included in the agenda of the G20, as the international community recognizes that “the G20 has a crucial role in advancing preparedness and responsiveness against global health challenges.”1 The G20 has both advantages and shortcomings in the field of global health governance. Active cooperation with the World Health Organization (WHO) is essential to enhance the G20’s capacity in global health governance and extend its global governance functions.

G20 Participation in Global Health Governance

As the priority of the G20’s global governance mandate remains in the economic field, participation in global health governance has so far been executed largely through informal mechanisms.2 However, as global health has gained importance on the G20 agenda, and in view of the risk of broken global supply chains and economic recession brought on by new and recurrent infectious diseases, full participation in global health governance has now become a historical responsibility and mission of the G20. The WHO Director-general Tedros Adhanom Ghebreyesus declared at the G20 Leaders’ Summit in June 2019 that health was a political choice, and that leaders of G20 members had a unique opportunity to make that choice for a better world.3 The G20 participates in global health governance generally

JIN Jiyong is Deputy Dean and Associate Professor at the School of International Relations and Public Affairs, Shanghai International Studies University.

1 “G20 Leader’s Declaration: Shaping an Inter-connected World,” Hamburg, July 7/8, 2017.

2 Andrew Cooper, “The G20 as an Improvised Crisis Committee and/or a Contested ‘Steering Committee’ for the World,” International Affairs, Vol.86, No.3, 2010, p.741.

3 Editorial, “G20 Osaka: When Will Global Health Commitments be Realized?”

No.10192, 2019, p.1.

The Lancet,

Vol.394,

in three ways: setting agendas, building financing mechanisms, and working with other multilateral institutions.

Setting the global health governance agenda

Agenda setting is a powerful tool for political stakeholders to exert and expand their influence. The G20 attempts to set the global health governance agenda in the following two ways.

The first is that the rotating host country can use the position of its presidency to influence the global health governance agenda. In the absence of a permanent G20 secretariat, the host country has a unique opportunity of shaping the theme of a leaders’ summit. In 2013, the German Ministry of Health released its first ever national strategy document for global health governance. It put the focus on “strengthening global health architecture,” emphasizing that “Germany has a special interest in effective and efficient global cooperation on health issues. The Federal Government is striving for a well-ordered and interconnected coexistence of international formats in the interest of coherent global health governance.”4 When hosting the G20 Leaders’ Summit in 2017, Germany managed to include health governance in the summit agenda and facilitated the very first Meeting of G20 Health Ministers, which has meanwhile become the most important annual G20 dialogue format for global health governance.5 In 2018, Argentina, as the G20 rotating presidency of the year, managed to put “malnutrition and overweight” on the agenda of the Meeting of Health Ministers. In Argentina, only 32 percent of infants under six months are exclusively breastfed, which is well below the South American average of 64.2 percent. Argentina’s adult population is also burdened by the problem of malnutrition. 18.6 percent of women of childbearing age suffer from anemia, and 9.9 percent of adult men and 9.5 percent of adult women have been diagnosed with diabetes.6 4 “Shaping Global Health, Taking Joint Action, Embracing Responsibility,” Germany’s Federal Ministry of Health, 2013, p.41.

5 Ilona Kichbusch, “A New Global Health Strategy for Germany,” British Medical Journal, Vol.366, July 26, 2019, p.3.

6 “Argentina Nutrition Report,” p.1, http://globalnutritionreport.org/media/profiles/v2.1.1/pdfs/argentina.pdf.

Inclusion of issues such as nutrition balance, obesity and diabetes into the G20 global health agenda would certainly contribute to solving the country’s public health problems. Japan, being the country with the oldest population in the world, has managed to include “response to population ageing” into the global health agenda at the third Meeting of G20 Health Ministers held in Japan in 2019. The Okayama Declaration released at the meeting’s conclusion recognized the necessity of building a sound medical system to address an ageing population, and emphasized the promotion of further research and development for healthy ageing, including for risk reduction, early detection, diagnosis, and treatment of dementia.7

Secondly, G20 leaders can set an example for promoting the composition of the global health governance agenda. To a certain extent, it was the personal effort of German Chancellor Angela Merkel that prompted Germany to participate in global health governance. At the Munich Security Conference in 2015, Merkel elaborated that the threat of the Ebola virus was an equally serious international matter as terrorism and forced migration.8 In 2019, then British Prime Minister Theresa May pledged US$1.8 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria. When she took part in the G20 Leaders’ Summit in Japan, she also urged “other international leaders to up their contributions to the fund to tackle three of the world’s deadliest epidemics.”9

The personal commitment of these state leaders has thus turned the concept of global health governance which was formulated at the G20 Meeting of Health Ministers into concrete collective action. The first G20 Health Ministers’ Meeting, convened in 2017, concluded with the Berlin Declaration titled “Together Today for a Healthy Tomorrow,” which focused on global health crisis management, strengthening health systems, and antimicrobial resistance (AMR). The G20 Health Working Group (HWG)

was established under the German presidency in the same year to “develop a shared international agenda on issues such as strengthening health-care systems, reducing malnutrition, health-crisis management and scaling up the fight against pandemics.”10 The initiatives coming from the G20 Leaders’ Summits have given health issues more prominence in global governance.

Participating in multilateral financing mechanisms for global health governance

Efficient global health governance depends on a stable financing mechanism. The G20 members account for 80 percent of the global economy and 75 percent of global trade, which undoubtedly makes it the largest contributor to financing a global health governance system. While the industrialized countries in the G20 lead the world in development assistance for health, the developing countries in the group have also made their due contributions.11 Major investments in global health have raised hopes that the G20 will be able to reshape the global health financing system. During the 2019 G20 Leaders’ Summit in Japan, the first Joint Meeting of Finance and Health Ministers was held to strengthen sustainable health financing. The conference came to the conclusion that “whole-of government and multisector approaches are crucial for improving efficiency and enhancing public financial management, with collaboration between finance and health authorities being the centerpiece of such approaches. While health ministries are in charge of designing high-quality, financially-sustainable, equitable and inclusive health policy, this mission cannot be completed by them alone; finance authorities have a joint responsibility in designing and securing financing sources for the health systems.”12

The G20 supports various types of global health financing by means of its Development Assistance Committee. Most developed countries in 10 OECD, “Global Health and G20,” 2017, https://www.oecd.org/g20/topics/global-health/.

11 Angela Micah, et al., “The US Provided $13 Billion in Development Assistance for Health in 2016, Less Per Person Than Many Peer Nations,” Health Affairs, Vol.36, No.12, 2017, pp.2133-2141. 12 “G20 Shared Understanding on the Importance of UHC Financing in Developing Countries - Toward Sustainable and Inclusive Growth,” June 6, 2019, p.2, http://www.g20.utoronto.ca/2019/annex8_1.pdf.

the G20 are members of the Development Assistance Committee of the Asia-pacific Economic Cooperation (APEC), an international development agency which prioritizes its global development assistance for health. In 2018, the Committee’s financial obligations were as high as US$38.9 billion for health, accounting for about 13 percent of its overall development assistance.13 In addition, the development assistance for health is also an important component of the G20 members’ respective official development assistance programs. Its function is to improve health care conditions in low- and middle-income countries, and to provide funding for developing countries through international organizations.14 The principal mechanisms of current global health development assistance include the WHO, the International Health Partnership and related initiatives, the Health System Funding Platform, the Joint United Nations Program on HIV/AIDS, etc.

The G20 also promotes the financing of global health programs through public-private partnerships. A public-private partnership is a new type of cooperation involving government and non-government funding for the construction of public infrastructure and the provision of better products and services to the general public. Public-private partnerships in the global public health sector encourage governments to share responsibilities and risks, participate in decision-making for global health, and take collective action to respond to any global health crisis with civil society and the private sector.15 The WHO has been promoting public-private partnerships as an important component of public health policy for the 21st century. These partnerships are now commonplace across the global health sphere, and are widely represented in the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunization, the International AIDS Vaccine Initiative, and the Drugs for Neglected 13 Joseph Dieleman, “Past, Present and Future of Global Health Financing,” The Lancet, Vol.393, June 1, 2019, p.2250.

14 Tang Kun, Zhao Yingxi and Li Chunyan, “The Development Assistance for Health, its Role of Coordination in International and National Assistance System,” China Public Health Management, Vol.5, 2016, p.632.

15 GAVI, “2018 Annual Financial Report,” and “The Global Fund, Pledges and Contributions Report 2019.”

Diseases Initiative. The G20 is actively involved in building public-private partnerships for global health, with nearly half of its members being important donors to the Global Vaccine Alliance and the Global Fund.16

Exerting influence on major multilateral mechanisms

The WHO and related United Nations agencies are powerful platforms to discuss issues of global health governance. The WHO is now in a phase of crucial transformation and transition, and the G20’s more active participation in global health governance will exert substantial impact on the WHO. In 2017, the Berlin Declaration released at the first G20 Meeting of Health Ministers stated that the G20 would comply with the International Health Regulations (IHR), support the leading role of the WHO in global health governance, and work closely with the organization to resolve global health crises. The Health Ministers urged the WHO to step up its reform of the funding system and make more effective use of its financial resources to respond better to global health emergencies.17 The Mar del Plata Declaration released at the second G20 Meeting of Health Ministers took a step further by calling upon the WHO to develop and improve the Contingency Fund for Emergencies (CFE), by reviewing its performance and demonstrating its benefits.18 In their Okayama Declaration, which was announced at the third G20 meeting, the Health Ministers promised that they would work together with the WHO for “Universal Health Coverage (UHC) by 2030.”19

The G20 development goals for global health are highly consistent with the UN 2030 Agenda for Sustainable Development, and they are therefore best suited to complement and reinforce each other, thereby becoming a duet in global health governance. One of the policy objectives supported by the G20 Meeting of Health Ministers is to facilitate the implementation

of the UN 2030 Agenda, because both share the common goal of achieving “universal health coverage.” The inclusion of the UN 2030 Agenda in the G20 global governance agenda will help “set a new medium- and long-term target for the G20 and overcome the confusion when formulating relevant policies within the Group.”20 By means of realizing the 2030 Agenda, the G20 may to a certain degree even transform itself from a mere crisis response mechanism to a long-term governance framework. A number of scholars have pointed to the fact that the sustainable development agenda explicitly calls for the participation of the G20 to lead the formation of global public health policies and guidelines, and to help achieve some of the public health goals of the United Nations’ sustainable development agenda.21

Motivations of G20 Participation in Global Health Governance

In the era of globalization, the mutual vulnerability in global public health security is affecting the entire international community, as any country may be hit by a health crisis.22 These common public health security challenges that every member is facing have motivated the G20 to actively participate in global health governance. While the WHO is confronted with many obstacles in executing global health governance, the G20 can take the initiative to act. The operating mechanism of the G20 allows for the inclusion of a broader health agenda and policy consensus, and is able to inject fresh impetus for its long-term sustainable development.

Common public health threats

The Ebola outbreak and the Zika crisis were the immediate reasons for the G20 to put global health issues on its agenda. When the Ebola epidemic

spread in West Africa in 2014, the international community realized it was exposed to “mutual vulnerability.” The first case of Ebola virus infection in the United States was confirmed in September 2014, and another case was detected a month later in Spain, showing that the virus had crossed “the Maginot Line” of the developed world to defend against infectious diseases and posed a direct threat to G20 members. Shortly afterwards, the Zika virus began to ravage the world. According to statistics, the costs inflicted by the Zika outbreak was estimated to range from US$7–18 billion over 2015– 2017 in Latin America and the Caribbean. Brazil, the United States and Canada might all be unable to withstand the consequences for their health and economic systems posed by the Zika virus threat.23

These above-mentioned public health crises directly led to the creation of the G20 response mechanism for global health security. During the Brisbane Summit in 2014, the G20 leaders announced the Brisbane Statement on Ebola, in which G20 members pledged to do whatever is necessary to ensure that international efforts would stifle the outbreak and address its economic and humanitarian costs.24 It was the first time since the G20 came into existence that leaders committed themselves in an official statement to jointly support a global health governance initiative.

Dysfunction of the global health governance mechanism

Although the WHO constitutes the most important multilateral global health governance mechanism, it has performed rather poorly in its reaction to recent global public health emergencies, and a lack of financial support has reduced its capacity to make independent decisions.

The WHO’S response to several global public health emergencies has been criticized as either an “overreaction” or as much too timid. Shortly after the H1N1 influenza outbreak in early 2009, the WHO declared

it “a public health emergency of international concern” and called upon countries to plan for the worst. The WHO was later accused of exaggerating the threat in order to attract large donations and help international pharmaceutical giants sell vaccines.25 An EU official even called it one of the biggest medical scandals of this century.26 By contrast, when the massive Ebola epidemic broke out and spread in the Republic of Guinea in early 2014, it was not until August 2014 that the WHO declared it “a public health emergency of international concern.” Due to the delayed reaction by the WHO the epidemic could not be quickly and effectively brought under control.27 The United Nations had to set up a UN Mission for Ebola Emergency Response to handle the situation.

Insufficient financial resources have additionally weakened the WHO’S capacity to make autonomous decisions. The budget of the WHO is made up mainly of membership dues and voluntary contributions for designated programs. The “zero-growth principle” in membership dues forces the WHO to rely heavily on voluntary donations, which come mostly from developed countries and account for more than 80 percent of its total budget.28 However, voluntary contributions do not necessarily bear any obligation in favor of multilateral governance, but might decentralize the authority of such an international organization to its donor countries, distort global health priorities, weaken organizational autonomy and global leadership, and even leave the decision-making credibility and legitimacy in question.29 Directorgeneral Tedros emphasized that the WHO must work hard to diversify its funding sources to avoid heavy reliance on certain donors.30 However, with a freeze on its assessed contributions, it is difficult to alleviate the WHO’S

heavy reliance on voluntary contributions in the short term.

Maintaining organizational vitality and considering policy preferences of members

As a multilateral cooperation mechanism composed of both developed countries and emerging economies, the G20 members have established an agenda setting model of mutual consultation on given topics before coming to an agreement, which helps to take into consideration policy preferences of individual members while continuously enlarging the framework of agenda. The G20 is constantly expanding its cooperation formats based on existing dialogue mechanisms, with issues ranging from global financial crisis response to transnational anti-corruption cooperation, from global energy governance and climate change to the reform of the international monetary system. In the course of this, a phenomenon can be perceived which has first been termed by neo-functionalist scholar Ernst Haas as the “spillover effect” theory of international cooperation. This describes a process in which new tasks of an organization would occur as a result of experience with tasks which the organization had performed or is performing.31 The experience and efficacy of the G20 in response to the global financial crisis and to energy governance may serve as a reference for its participation in global health governance, which illustrates a “functional spillover” from the economic to the public health sphere. Some scholars believe that agenda setting and its efficacy is one of the central elements which may help sustain the G20’s further development and vitality.32

In terms of setting specific agendas, an open discussion on topics is a good basis to ensure a high degree of flexibility for the G20’s response to different international situations. To take global health governance as an example, the G20 has already participated in a wide range of relevant programs, including the universal health coverage and the accessibility of medicines, which are

the concerns of developing countries, as well as antimicrobial resistance, the challenge of ageing population, and the establishment of a global infectious disease surveillance system, which are followed by the developed world.33 Any improvement of global health governance requires professional knowledge on behalf of decision-makers, for which the Meeting of G20 Health Ministers provides a good starting point. Such informal agenda setting procedures make it possible for global health issues to be included in the G20 agenda, and also provide impetus for the G20’s long-lasting sustainability.

Advantages and Challenges

The G20’s informal organizational structure without a permanent secretariat embodies greater flexibility and inclusiveness, which helps reduce negotiating costs and decrease power struggle and hegemonic governance in international cooperation.34 Since its founding in 1999, the G20 has perceived development as its mission, and has gradually extended the discussion on development issues. In 2005, the promotion of a “balanced and orderly world economic development” became the headline topic of the G20 meeting in China.35 The G20 consultation mechanism for mutually beneficial development sets countries free from the security dilemma in traditional international cooperation. At the same time, flexibility and inclusiveness also has its pitfalls, because it takes the collective effort of members to effectively translate a “gentleman’s agreement” or a consensus into real action.

Advantages of G20 global health governance

The inclusive consultation mechanism of the G20 can help manage the transition in global health governance from “governance by developed

countries” to “joint governance by developed and developing countries.” The G20 is composed of four sub-groups: the United States, Europe and Japan; the BRICS countries; medium-sized powers; and international organizations. Their respective positions are largely determining whether the G20 transformation will be a success or a failure.36 The G7, which represents the developed countries, and the BRICS group, representing emerging economies, are the two most dynamic forces inside the G20. Regarding the global health governance agenda, the G7 had held seven meetings of their health ministers as of the end of 2019 compared to eight by BRICS countries. It shows that the G7 and the BRICS have each formed relatively mature health governance cooperation mechanisms of their own, and both blocs will most likely bring their proposals to the negotiating table to work out a consensus within the G20 multilateral framework.

In addition, cross-sectoral cooperation within the G20 makes it possible to achieve an internal balance between the developed and developing world. International mechanisms are usually dominated by the interests and policies of major powers.37 In the past, Western industrialized nations had most of the say and decision-making power in global health governance, whether it concerned patent protection of pharmaceutics in the World Trade Organization (WTO), or how the obligations of developed countries to assist developing countries were understated in the WHO’S International Health Regulations. Under the G20 framework, developing countries are now in a better position to have their voices heard and participate in the decision-making, which enhances the legitimacy and the fair distribution of decision-making power in global health governance. “Inclusive competition” between developed and developing countries within the G20 has proven to be an advantage of the new type of multilateral international cooperation mechanism when it comes to efficiency in global health governance.38

39

Robert Jervis, “Cooperation Under the Security Dilemma,” World Politics, Vol.30, No.2, 1978, p.196.

40 “Declaration on Delivering Resources through the International Financial Institutions,” London Summit, April 2, 2009, p.1, http://www.g20.utoronto.ca/2009/2009delivery.pdf.

41 “G20 Action Plan on the 2030 Agenda for Sustainable Development,” September 20, 2016, p.14.

42 Robert Benson and Michael Zurn, “Untapped Potential: How the G20 can Strengthen Global Governance,” South African Journal of International Affairs, Vol.26, No.4, 2019, p.7.

43 Steven Slaughter, “The Prospects of Deliberative Global Governance in the G20: Legitimacy, Accountability, and Public Contestation,” Review of International Studies, Vol.39, No.1, 2013, pp.71-90.

44 Johns Hopkins Coronavirus Resource Center, “Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering,” April 22, 2020, https://coronavirus.jhu.edu/map.html.

45 Richard Partington and Phillip Inman, “Coronavirus Escalation Could Cut Global Economic Growth in Half,” The Guardian, March 2, 2020.

46 World Trade Organization, “Trade Statistics and Outlook,”april 8, 2020, https://www.wto.org/english/ news_e/pres20_e/pr855_e.pdf.

47 Robin Niblett, “The End of Globalization As We Know It,”

Foreign Policy,

March 20, 2020.

48 “The Standing Committee of Political Bureau of the Central Committee of the CPC Meets to Discuss the Prevention and Control of the Coronavirus,” People’s Daily, January 26, 2020.

49 Noemie Bisserbe and Stacy Meichtry, “France’s Macron Urges Global Effort to Contain Coronavirus,” Wall Street Journal, March 12, 2020.

50 “Extraordinary G20 Leaders’ Summit Statement on COVID-19,” Xinhua,

March 27, 2020.

51 “Extraordinary G20 Leaders’ Summit Statement on COVID-19,” March 27, 2020.

52 Michael Holden, “UK Pledges 200 Million Pounds in Aid to Help Stop Second Coronavirus Wave,” Reuters, April 12, 2020.

53 “Extraordinary G20 Leaders’ Summit Statement on COVID-19,” March 27, 2020.