A paradigm shift in global health governance
The global health community, national security agencies and all governments have known that a pandemic like COVID-19 was likely to come, yet global health policy has remained woefully unprepared nor fit-for-purpose. In 2015, the G7 members proclaimed that Ebola had been a ‘wake-up call’ for the need for better global cooperation. It was also recognised that antimicrobial resistance (AMR) threatened to kill 300 million people by 2050, thus demanding urgent action. Yet little has been done to address these existing global health governance shortcomings.15
For example, the lauded G7 and G20 response, the Global Health Security Agenda (https://ghsagenda.org/), continues to speak in the terms of costly ‘counter-measures’ versus prevention and health system strengthening. Moreover, the Pandemic Emergency Financing Facility (PEF) (https://www.worldbank.org/en/topic/pandemics/brief/pandemic-emergency-financing-facility), meant to deliver up to $500 million in epidemic assistance to curb expansion into a pandemic, sits idle as a complicated ‘loan mechanism’ at the World Bank, available to only a few countries (eg, China and India do not qualify for the money). There is also serious ambiguity about how the PEF intersects and/or complements the WHO’s Contingency Fund for Emergencies (CFE) (https://www.who.int/emergencies/funding/contingency-fund-for-emergencies). The CFE is available to more countries for more risks, and more quickly, but represents far less money than the PEF (which, in theory, should come after the CFE, if you happen to prequalify for the loan).16 The ‘One Health’ approach, which was meant to offer a more responsive research and policy agenda to combat zoonotic diseases, remains sluggish at best and underdeveloped in terms of including environmental factors, such as soil and water, which play a crucial part in AMR and other threats.17
In terms of pathogen monitoring and response, the 2005 International Health Regulations, which are meant ‘to help the international community and governments prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide’,18 are not fully implemented by many countries due to limited financial resources and political will, and have been violated in response to the COVID-19 outbreak.19 What is more confounding is that many high-income countries like France have failed to fully implement the International Health Regulations, particularly in their overseas territories.16 In addition, other disease control mechanisms, like the WHO Global Influenza Surveillance and Response System (https://www.who.int/influenza/gisrs_laboratory/en/), remain inadequate and underfunded, with too few WHO laboratories and a market-based model where a global public good (pooled influenza knowledge) is turned into a private good (pharmaceutical profit), with historical inequities in terms of public health.20 Moreover, many countries, like China, are incentivised not to raise the epidemic alarm too soon due to fears of diminished direct foreign investment (like with severe acute respiratory syndrome, H7N9 and now COVID-19) and fears that the government will be perceived as weak.21
These conditions of incapacity at the international level are exacerbated by a weakened WHO, whose budget has been radically reduced and ring-fenced. For example, the WHO used to receive three-quarters of its financing from assessed contributions levied on members. However, a change to a zero real growth policy for its regular budget in the 1980s has meant it now only receives a quarter of its budget from member contributions. As a result, the WHO is dependent on extra-budgetary ring-fenced ‘pet project’ funding from donors to fill an increasingly shrinking budget.22 As the money flows to other multilateral health initiatives, the WHO’s authority dissipates, with numerous organisations like the Institute for Health Metrics and Evaluation, the Bill and Melinda Gates Foundation and Médecins Sans Frontières able to command greater epistemic authority,23 financial influence24 and response effectiveness.25 However, this expansion of initiatives creates a condition of policy fragmentation, which significantly weakens coordinated global public health.26 27
One real result of fragmentation of global health governance is an inefficient division of labour, where hundreds of actors such as the WHO, Global Fund, President’s Emergency Plan For AIDS Relief, United Nations Programme on HIV and AIDS, United States Agency for International Development, World Bank, the Gates Foundation and the Clinton Foundation (to name only a few) produce parallel programmes or bric-à-brac vertical health silos that have neither generated overall system strengthening in high burden countries nor allowed for effective global health policy.27 28 This creates two failures. First, contrary to sector-wide approaches,29 vertical ‘pet-project’ global initiatives often fail to promote sustainable long-term local health system strengthening, which is the best preventive defence for disease control (of all types, not just infectious diseases). Second, the global level is woefully unprepared for epidemics, since global policy has remained reactionary, symptom-based and dependent on vaccine discoveries without full appreciation of other upstream determinants of disease and access to those vaccines.
Given the state of global health governance and inadequate investments in health system strengthening—as well as the failure, by many actors, to adopt a ‘systems approach’ to problem resolution14—the spread and danger of COVID-19 is not surprising. What is required, we argue, is to shift global health policymaking from a specific reactional paradigm to a systemic, holistic and preventive paradigm. There is no doubt that this approach will require serious resources, governance reform and political will. Nevertheless, the global economic costs of COVID-19 have already reached into at least a trillion dollars.30 Thus, serious efforts to improve global and local health systems would be a small fraction of this cost, with a tried and true cost-saving philosophy that ‘an ounce of prevention is worth a pound of cure’.