Where is the greatest need to reform the global health architecture?
Architecture is probably not the right word because it’s currently so fragmented. Any building designed like that would collapse. I like to call it an ecosystem. I think in terms of the ‘what’, the ‘how’ and the ‘who’.
The ‘what’ is that the system is failing to address the main developments in disease, both epidemiologically and demographically. The system still focuses mostly on infectious diseases, not on what’s killing or harming the most people.
Second, the focus should be more on system and resilience building and prevention, rather than vertical disease-specific siloes. Health must be viewed as fundamental for economic and societal development.
The ‘how’ is probably the most important and most challenging to address. The system is no longer fit to produce the best health outcomes for countries. There is an important role for financing institutions such as the Global Fund, Unitaid and Gavi, but currently the real burden falls on countries, often with limited administrative and planning capacity. Real progress requires a country-led approach, supported by further consolidation and coordination at the regional and global levels. There have been many attempts to do this, but frankly, none has worked.
In addition to financial pressure, sovereignty is politically important. So, on the ‘how’ I would distinguish between financial support and the provision of global public goods, which will always be needed. In an ideal world, official development assistance would no longer be needed, but the core normative and convening functions of the World Health Organization will still remain.
On the ‘who’ – we have to be specific. We will always need a WHO but not the same as the one we have now. We need to refocus. It’s in everybody’s interest. For other global health institutions, we should aim for a rational consolidation, and in some cases, closure in the next 5 to 10 years.
But I don’t know of a single organization that has fundamentally reformed itself. There’s no incentive to do that. We need to think critically in terms of incentives – what would make this possible – and that’s fundamentally a political issue. Identifying the incentives for the global health industrial complex (as I now call it) to adapt and change – that is the next question.
How does the Accra Reset fit into this picture?
The Accra Reset, launched by Ghana’s President John Mahama, comes from countries across the ‘Global South’ – I haven’t found an ideal term – saying that they need to be at the core of setting the agenda and priorities. The classic model has been that the donors, with the best of intentions, agree on the priorities, the coordination and reform, and then ask countries from the South to sign on. Here it’s turned it upside down, with the initiative, agenda and priority-setting coming from the low- and middle-income countries. It’s realistic, in that domestic financing must be at the core of dealing with the health of citizens. At the same time, regional and global cooperation will remain essential for the provision of global public goods, especially for countries in crisis. We need a transition, but this is not going to happen overnight.
There’s also a link with a political agenda calling for more sovereignty in terms of local and regional manufacturing which can create a far more equitable distribution of capacity. Manufacturing is about sovereignty, as well as economic and societal development. And it makes me more optimistic, being linked to a political process. Nigeria has a presidential initiative to develop a health value chain, which involves supporting local manufacturing as well as creating employment, creating opportunities for local innovation and so on. In the long run, that’s a better approach than trying to negotiate the lowest price from a Chinese or Indian manufacturer.
How can health be integrated into the political and economic process?
Something I learned from working on HIV was that if we stick to health ministries, there’s no way we can make progress.
After I had been head of UNAIDS for a few years, I thought I was a total failure because more people died and more people got infected every year. I called a meeting of friends and critics, and we concluded that only two things mattered: the economy and security. And that’s the political reality. So I was the first to bring a non-classic security issue to the United Nations Security Council, the UN General Assembly, the World Economic Forum and ministers of finance and so on to try to reframe the whole public health issue as a core component of development, from the perspective of political economy.
But as we say in my first language, Dutch, we only learn by falling and standing up. Health has become part of the political economy, but now there are geo-economic challenges because of trade, tariffs and sovereignty. This could help. When you look at demographic developments – Nigeria alone will have more citizens than the US in 2050 – there will be markets there. And from a European perspective, without solid development, in sub-Saharan Africa we’ll see hundreds of millions of people knocking on our doors.
Health must become part of the core geopolitical agenda together with climate change and industrial development. Without that I’m not very optimistic for the future of our world. But the global health community, as far as I can see, has not yet internalised this need.
