The Need for a Geopolitical Shift in Global Health
Richard Seifman has over 45 years experience in international development with bilateral, multilateral and non-governmental organisations, with his current focus on pandemic preparedness and the One Health approach.
Ok Pannenborg was among the early protagonists of global health since the 1960s, worked mostly in Asia and Africa for U.N. agencies, non-governmental organisations and the Netherlands Government, and served as the most senior technical health leader at the World Bank until earlier this decade.
However, as Pablos Mendez and colleagues have highlighted, this field is overdue for a major renovation. Over time the House of Global Health, which was designed and built primarily by the industrialised democracies, has added too many wings, cellars, attics, and garden sheds. It is increasingly looking like it will collapse under its own weight. To call the roll of international health structures, even in acronymic form—WHO, UNICEF, UNFPA, UNAIDS, IAVI, GAVI, the Global Fund, Vaccine Alliance, Stop-TB, Roll-back-Malaria, Malaria-No-More, BMGF, Chan-Zuckerberg Foundation, the Children’s Investment Fund, the World Bank, IFC, GFF, TDR, CEPI, ECDTP, USAID, DFID, CDC, NIH, GHIF, Wellcome Trust, NORAD, CUGH—is to invite exhaustion. Each disease, each intervention, each funding arrangement, each innovation approach has its own room, often without connecting doors or even windows. Returns are diminishing and confidence is faltering in many of the people or institutions living in this house.
The mere number of players is not necessarily a problem, but the changing nature of global power structures certainly is. Almost all the inhabitants of this house are from the traditional 20th century OECD homestead. The recently appointed head of the Global Fund was yet another colleague from the UK. The World Bank and IMF remain stuck in a USA-Europe gentlemen’s agreement regarding their chiefs and controlling voting power and, as such, in a 20th century mindset.
Meanwhile, China has established the new Asian Infrastructure Investment Bank (AIIB)—a direct result of the traditional powers’ unwillingness to allow China to take a proportional role. China’s Belt and Road Initiative conveys a strategy that the world’s most populous nation will go it alone: it does not need nor wants the traditional global players to fund and implement its objectives (including the UN’s SDGs). And it is making its overseas investments largely without the “Western values” conditions, such as safeguard policies with respect to environmental concerns, involuntary resettlement, indigenous people, pest management, human rights, ‘democracy’ or free trade approaches. Such ‘conditional’ policies are less attractive to many developing countries. The AIIB recently announced a strategic link-up with the Islamic Development Bank (ISDB): together with China’s Silk Road Fund they are capitalised at approximately US$300 billion; the World Bank is capitalised at around US$270 billion, with less than US$16 billion paid—in capital. Together with the Belt and Road Initiative, it seems only a matter of time before China’s international health programs will encroach on, and possibly topple, the house that Global Health built.
For now, the United States is still by far the largest global health funder in absolute amounts but the Trump Administration’s turn inward, and its proposals to slash spending on global health, is another crack in the foundation of the Global Health House. Look at what’s happening in several other OECD countries: the Netherlands no longer has a Ministry for Development Assistance; that field is now subservient to the country’s trade agenda; Canada, Denmark, Austria, France, Italy, and others have abolished or downgraded their aid agencies and reallocated their funding.
Capital movements from the private sector have been exploding, to the point at which they now dwarf external public-sector financing. In addition, countries are spending more of their own money on public health than they are receiving in foreign aid, and those investments will grow (see the 2015 Addis Summit). Financing from donors is becoming proportionately smaller and smaller. With economies in the traditional OECD countries shrinking in relative terms and global population approaching 8 billion people, it makes for a very different picture than that at the turn of the century (beyond 2050, the traditional global health core countries may account for less than 10% of world population, with 90% in the former South). The wealth of Bill Gates, Mark Zuckerberg and other billionaires may mitigate the trend for a while, they will prove no match for the geopolitical shifts under way.
What to do? We suggest a few approaches that may help sustain, and possibly expand, the global public good nature of many of the current global health commitments.
First, open the windows already. The OECD countries need to change from looking inward to actively pursuing a policy of strategic inclusion, one that drops their top-down, sometimes still neo-colonial subcultures and lets the emerging forces have real political influence and financial and technical contributions. The powers of the last century must realise that the world is no longer the same.
Second, give the current structure an efficiency makeover. Start by merging all the non-infectious disease agencies into one, whether they deal with control, research, innovation, surveillance, technical assistance, or implementation support. Put them all— GAVI, UNAIDS, RBM, TDR, CEPI, EDTCP, the Global Fund, UNICEF, FIND, IAVI and others—in one room and make them play together. Fundamentally redesign WHO and give it a room on the regulatory floor: let it provide the standards, norms and treaties, while others do the implementing. Then put all the financing girls and boys together in a new global health financing agency (e.g. merge the World Bank and the Regional Development Banks, with a new HQ in Asia or Africa) and build a door so their private-sector cousins can visit and coordinate on broader goals. And finally, establish a central living room where everyone in the global health family will have to convene and commit to delivering more than the sum of their individual activities as measured by standards of global public goods.
Third, do something big. After World War II, broad-based support coalesced around the need for a collective response to organize the global economy, eg, through the Bretton Woods agreements and the Marshall Plan, where economic thinking evolved to incorporate a market-oriented reform approach for developing countries. Global health needs to be similarly bold and creative now. The West and the East collectively need to find a new path to address global health challenges, incorporating a wider palette of underlying values, cultural constructs and economic models. Indeed, not to do so would be to relegate all of us to a lose-lose outcome. Failure to act by the traditional Western global health powers and at least start repositioning themselves geopolitically will likely render them increasingly obsolete and irrelevant by the end of the century.
We need something like a Bretton Woods Conference on Global Health in the 21st Century. This time, the convening architects would consist of old and new leaders, namely China, the European Union, Russia, Japan, India, the USA, as well as regional leadership from the Middle East, Africa and Latin America. Such a conference would explicitly recognise the new geopolitical power structures and hammer out fairer roles in leadership and decision-making.
The above may well be an illusion, of course. How do we know the new structures would do better than what we have now? Do we really think the banks and UN agencies will allow reducing their current power? Nevertheless, the business in our global health house is deeply changing, our house is getting old and there are no rooms for the new generation at the door: it is simply no longer fit-for purpose. Let’s call in at least the young architects and start discussing the redesign. Tomorrow, if not yesterday.