• global health
• global health strategy
• Germany
• fairness
• decision making
• accountability for reasonableness

During the past decade, Germany has increasingly taken on a leadership role in global health.1 Facing the changing global political landscape, the German government under Chancellor Angela Merkel initiated a process to develop a new global health strategy in June 2018. Following a public kick-off meeting, five stakeholder groups—representatives of the civil society (non-governmental organisations), think tanks, private sector, academia and youth organisations—were invited to provide input through position papers. These are expected to be considered in interministerial discussions on the new strategy, which is scheduled to be adopted by the end of 2019.

We welcome this new initiative, which is an opportunity for Germany to extend its current global health strategy, adopted in 2013,2 and to further define and strengthen its role in global health. In doing so, Germany has to strike a balance between underlying diverging strategic considerations, as the decisions made in the previous global health strategy have been subject to criticism (eg, different perceptions regarding the role that the German healthcare industry should play).3–5

Such strategic considerations may include (1) paying tribute to Germany’s role within the international community and global collaborative efforts versus advancing an independent agenda; (2) building on Germany’s particular strengths (eg, environmental health) versus using the strategy as an opportunity to address new and currently neglected areas (eg, road traffic injuries); and (3) strengthening health security and ensuring economic prosperity (‘inward looking’) versus promoting the health and development of other nations in close collaboration with these nations.

In the context of such strategic considerations, a plethora of global health challenges and limited resources, the decision-making process will be a challenging and controversial task. As there is no consensus on the right or best reasons by which to prioritise issues or value outcomes, reasonable disagreement about the right or best decision is likely in pluralist societies.6 Therefore, the question of how a decision is made as well as the need to strive for decision-making processes that are regarded as fair by those involved gain particular importance.6 7

A number of recommendations to achieve fair decision-making processes have emerged from the Accountability for Reasonableness framework,6 among others.8–13 Their consideration can help ensure that the development process is undertaken in the best possible manner and will lead to a global health strategy with broad support from the German society at large. The recommendations include the following: decisions should be based on sensible and ethically defensible reasons that are formulated explicitly and made public; effective stakeholder participation and public involvement should be facilitated, including the possibility of appeals; conflicts of interest should be effectively managed; and processes and institutions should be in place to implement and enforce these conditions in an effective manner.

The selection of stakeholders who should participate in the process is in itself a normative decision with a profound impact on the outcome of the process. We agree with those who argue that one condition of a fair process is to include those populations who are directly and indirectly affected by the decision.9 This includes those deciding on and eventually implementing a German global health strategy, those intended as beneficiaries as well as those at risk of (unintended) harm.

Limitations in available resources and the possibility of adverse consequences furthermore imply a need to ground decisions in research evidence. In some areas, evidence is readily available, for example, epidemiological data provided by the Global Burden of Disease Study and data on the effectiveness of interventions provided by Cochrane and the Campbell Collaboration. In other areas, the evidence is very limited, and such uncertainties should be made transparent in the decision-making process. Reducing existing uncertainties surrounding key global health challenges would in itself be a valuable goal of the new global health strategy.

To date, the process initiated by the German government has shown much promise with regard to these recommendations: The government has anchored the development of its new global health strategy in an interministerial process (reflective of the health in all policies concept), has actively sought inputs from German stakeholder groups and has set up an International Advisory Board on Global Health, which includes representatives of the WHO and donor organisations (eg, the Bill and Melinda Gates Foundation).14 Furthermore, in addition to recommending priority fields, the stakeholder groups have been encouraged to suggest guiding principles: This is a valuable opportunity to jointly develop and publicly discuss the normative reasoning underpinning the selection of global health priorities in the new strategy and to help guide the strategic decisions to be made.

In moving forward, it is paramount that the above-mentioned recommendations on a fair decision-making process continue to be considered in the development and, ultimately, implementation of the strategy:

• First, priorities in the global health strategy, as well as the principles underpinning the adopted decisions, should be documented in a transparent manner. This includes documenting the supporting research evidence, as well as an explicit and critical reflection on the normative reasoning applied (eg, why research on obesity was selected as a priority over neglected tropical disease, or vice versa).

• Second, an effective management of conflict of interest should make the involvement of different stakeholders and their specific contributions public. This allows for public scrutiny and an open discussion to determine whether any conflicting interests of stakeholders have been addressed and balanced out in an acceptable manner.

• Third, the input already provided by the five stakeholder groups should truly be taken into consideration during the interministerial decision-making processes. To further enhance public participation, drafts of the strategy should be made available to selected stakeholder groups or the public at critical transition points, allowing for appeal and revision. It may also be helpful to examine the forms of public participation that countries, such as Canada, the UK, the Netherlands or Switzerland, have used for making strategic health decisions.

• Fourth, in the light of global health being a holistic, multisectoral and transdisciplinary concept, the government should critically reflect on the stakeholders to be consulted within Germany. The current dominance of the medical and healthcare sector may need to be redressed to include a broader range of disciplines (eg, sociology, ethics) and sectors (eg, economics, agriculture, environment), in particular in view of complex multisectoral global health challenges, such as mitigating and/or adapting to climate change in the light of its health impacts.

• Fifth, as the new German global health strategy is likely to have a profound impact on populations in low-income and middle-income countries (LMICs), representatives of their populations should be given the opportunity to directly voice their interests and concerns, too. We therefore welcome the expansion of the International Advisory Board on Global Health in July 2018, which now includes three (out of ten) members from LMICs.14 However, two of these are current or former WHO staff, with the third representing a think tank from a middle-income country, suggesting that the nomination of additional LMIC stakeholders (eg, representing civil rights, poverty action or patient organisations) may be warranted.

• Last, once the new German global health strategy is adopted, the government should monitor its implementation on a regular basis, evaluate its successes and failures, and make adjustments where necessary. At these stages and tasks should the government strive for public participation and transparency.

Germany has the opportunity to take on a strong position in the dynamically evolving global health landscape. With a commitment to fair and transparent decision-making processes during development, implementation and evaluation of its new global health strategy, Germany can contribute to broadening the scope of governmental action on global health and to shaping the way global health will be conceptualised and practised in the coming decades.