The Ebola crisis prooved, that the G20 aims to ensure infectious agents to not cross borders rather than acting in disease prevention. This is why there is a serious concern that public health needs of poorer countries will be ignored.
In contrast to the G8/G7 processes, global health never played a big role in the G20 deliberations until recently. But in 2014 global health finally muscled its way on to the G20 agenda. More than 11,000 lives were lost in West Africa due to a weak and slow international response to the Ebola outbreak. This revealed that in today’s highly mobile and inter-connected world, institutions are currently either unable or unwilling to respond to a rapidly spreading health crises in a rapid and effective manner. This scared the Group of 20 into action: Many argue that the prime drivers of this action are global health security deliberations – so protecting the own population from outbreaks– rather than a needs-based motivation focussing on poorer countries that are facing huge health challenges.
Reacting hurriedly, the 2014 Australian G20 Communiqué limited itself to better managing future health crises, strengthening health systems globally and tackling the emerging threat of anti-microbial resistance (AMR).
Unfortunately, the 2015 Turkish G20 Communiqué just acknowledged “global health risks, such as antimicrobial resistance, infectious disease threats and weak health systems.” The only stated resolve was to “discuss the terms of reference to deal with this issue in the next year.” This year’s Chinese G20 Communiqué, however, altogether dropped any mention of health - other than wanting to “promote prudent use of antibiotics and take into consideration huge challenges of affordability of and access to antimicrobials and their impact on public health.” In this regard the annex of the Communiqué demonstrates at least some acknowledgement of one of the major challenges in the global health sector; the G20 affirms the need to unlock research and development (R&D) into new and existing antimicrobials, wants to promote the prudent use of antibiotics, and takes under consideration the huge challenges of affordability of and access to anti-microbials and their impact on public health. Even though crucial gaps also exist in regard to affordable access to health priorities other than anti-microbials, such as research and development for poverty-related, neglected, and new and emerging diseases, the Chinese G20 Communiqué does not provide adequate answers.
So far, there is no official G20 commitment on global health on record.
This is bound to change. Previously, global health challenges were being discussed in a dedicated health working group. However, with the newly minted “G20 Action Plan on the 2030 Agenda for Sustainable Development”, the G20 has declared that health is one of 15 Sustainable Development Sectors (SDSs) and should prominently figure in the deliberations of the Development Working Group. It will be up to Germany, host of the next summit, to put this into action. (See also Theme #10 on the SDG of this series).
What the agenda ought to be
Health is not only an outcome, but also a precondition for human development. Also, health involves more than crisis management. Every person has a right to health.
When Ebola broke out in West African communities, there was not only a shortage of health workers in the region. There was also a lack of medical equipment; health systems were not prepared for rapid crisis management. Whereas tackling an international global health crisis such as Ebola requires strong crisis management mechanisms, preventing daily health crises that are often overlooked, requires universal access to quality health coverage. This requires quality health products – vaccines, diagnostics and medicines that cover specific needs of populations in the Global South. The case of Ebola demonstrates the limited ability to provide those basic services when most needed: A promising vaccine candidate that was publicly funded stayed at the basic research stage for more than ten years. It did not enter the applied research stage of clinical trials that is usually conducted by commercial pharma companies. As a result, the world was left without any means to adequately prevent the spread of Ebola in West Africa at the time.
From an economic point of view, the lack of R&D constitutes a market failure within the innovation structure - a failure that affects the health needs of people globally - and thus needs global answers.
Concerted efforts must be made to close existing research gaps. This will require the definition of concrete research priorities as well as increased promotion of alternative incentive models for innovations. Importantly, the costs for R&D are delinked from the price (the so-called de-linkage concept) of the final product. This is the only way to ensure that urgently required R&D activities take place and final products are affordable globally, without having high prices and high profits, which today serve primarily as motivations for companies to make R&D investments. The G20 has to ensure that all people have access to the quality health products and services they need, without falling into financial hardship. To follow this through, they should strengthen the World Health Organizations´ institutional capacity and mobilize the necessary funds.
Any G20 measures in regard to the promotion of R&D in the context of AMR should also particularly cover health needs resulting from a lack of adequate diagnostics and medicines to tackle drug-resistant tuberculosis (DR-TB).
Limitations regarding commitments
So far, unfortunately, the G20’s pace with regard to Global Health is proceeding at glacial speed, mimicking the world’s slow and inefficient response to the Ebola crisis. Worse, the current - very limited - debate takes place under the heading of ‘health security’, which expresses the G20 needs in terms of disease prevention and ensuring that infectious agents do not cross borders. That is why there is a serious concern that public health needs of poorer countries will not be taken into consideration.
Progress over time
As mentioned above, there are so far no concrete political commitments by the G20 – except for declarations of intent on anti-microbial resistance (AMR). However, clearly stating the threat of AMR should receive an “honourable mention”. The G20 is waking up to the fact that diseases that can be treated today may become untreatable, if there is no immediate action. AMR is a universal problem that affects both rich and poorer countries.
The G20 should strengthen the role of the World Health Organization (WHO) that is democratically mandated but insufficiently resourced to deal with the challenges.
But given that health made it onto the official G20 agenda, it is high time that global health is discussed by the G20 as a human right and not just as protection from disease. The Alma Ata Conference in 1978 defined global health in its declaration as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." It is both a precondition and goal of sustainable development, and therefore requires a multi-sectoral and multi-disciplinary approach.
For this purpose, the Sustainable Development Goals are a good point of departure as they clearly point out who needs to be reached first and foremost: "As we embark on this great collective journey, we pledge that no one will be left behind" (§4, 2030 Agenda). Last year, all G20 members committed to "endeavor to reach the furthest behind first". Roughly two-thirds of all unnecessary deaths of children less than five years old occur in G20 countries. It is therefore imperative that the G20 states ramp up its efforts to provide Universal Health Coverage to their citizens, beginning with those at the margins of society, such as people with disabilities, without official documentation, those in hard-to reach geographical areas, ethnic minorities and people discriminated due to their sexual orientation and identity.
The role of the engagement groups
Some members of the Civil 20 (C20) Health Working Group produced a position paper referring to the G20 process and global health. The list of demands follows.
The German G20 presidency should coordinate with the UN system and other international organizations to:
- strengthen gender equality, sexual & reproductive health and rights of all people within the framework of gender policy and global health policy;
- reflect the child rights-based and gender transformative approaches of implementing the 2030 Agenda in national strategies and plans (in particular SDG 5);
- prioritize maternal and child health as 'unfinished business' of the MDGs by focusing on universal access to health;
- explicitly define the needs of vulnerable groups, and include these groups into program, legislative and social planning, which should have as their aim to achieve health service access for all groups within five years;
- define global health in the spirit of Alma Ata and build on the G7 priority areas of the German and Japanese presidencies, rather than focus narrowly on global health crisis management;
- support Universal Health Coverage, prioritizing the above-mentioned vulnerable groups, ensuring that local and community-based health services can partake in prevention, surveillance, rehabilitation and have sufficient funding for services, technical appliances, support services, etc. that can be tailored to specific needs (e.g., disability);
- strive to have the coordinating role of a sufficiently funded World Health Organization recognized by the G20 partners including financial commitments following the WHO recommendations of 0.1% GNI for global health that supports sustainable health system strengthening;
- continuously gather and publish comparative and disaggregated data on health services (in particular for vulnerable groups such as those mentioned above); and
- support and fund biomedical research and development in order to ensure that health systems can provide the services and medical products tailored to the specific needs of people living in developing countries, such as poverty related diseases, neglected tropical diseases, and new and emerging diseases.
- strengthen new models for biomedical research and development that decouple research costs from final prices and sales volumes (de-linkage) while all efforts should be coordinated under the lead of WHO;
- initiate a high-level political process to implement the recommendations of the UN Secretary General's High Level Panel on Access to Medicines which embraces access to vaccines, diagnostics and drugs in a financially viable manner;
- improve access to existing vaccines and diagnostics, thus reducing the use of antibiotics;
- strengthen health systems in a way that the rational use of antibiotics prevents a further expansion of resistance;
- support an internationally coordinated process to develop new antibiotics and their effective, rational and sustainable use;
- support for the 3P (Push-Pull-Pool) Project to bring about a new pan-TB regimen and more effective and more affordable DR-TB treatment regimens through innovative push and pull incentive mechanisms (upfront grants and financial prizes), and an open-collaborative approach to drug development (pooling data and intellectual property); and
- ensure that international free trade agreements do not include clauses that could restrict the international access to affordable vaccines, diagnostics and drugs.
Apart from this coalition of NGOs, a group of actors in health politics in Germany (Confederation of German Trade Unions (DGB), associations of social interest groups, scientists, professional associations and development organizations) have founded the German Platform for Global Health (Deutsche Plattform für globale Gesundheit, DPGG). The advocacy and policy orientation of DPGG is primarily deduced from social and political determinants of health. As a result, DPGG positions are, at least in part, incompatible with some of the views expressed in this paper.
After Federal Chancellor Angela Merkel had made health one of the priorities of the 2015 German G7 summit at Schloss Elmau, the dialogue on this issue was continued at the Japanese G7 summit at Ise-Shima and will now also be on the German G20 agenda. This is to be welcomed. A structural approach to address the pending problems, however, will require concerted efforts of the G20 nations to strengthen the health systems and increase public research funding. For the first time ever, the research academies have joined forces under the “Science 20“ program and will have the potential to tackle some of the problems by joint projects and well-coordinated research based on the principle of division of labor. The civil society representatives working in the health sector will monitor the process and the outcomes very closely and voice the demands mentioned above.
This article is part of our dossier "G20 in Focus".
 G20 Leaders’ Communiqué Brisbane Summit, 15-16 November 2014.
 G20 Leaders’ Communiqué Antalya Summit, 15-16 November 2015.
 G20 Leaders' Communiqué Hangzhou Summit.
 The original text with the full quote can be accessed here: drive-ab.eu.
 Transforming our World: The 2030 Agenda for Sustainable Development, United Nations, 2015.
 G20 and Global Health, Attaining the Sustainable Development Goals of the 2030 Agenda
 A position paper by the DPGG in German can be found here: www.plattformglobalegesundheit.de. This paragraph has been inserted by the editors.