Time for a Jubilee
According to Remco van de Pas (Institute of Tropical Medicine, Antwerp), SDG3 on health and wellbeing has been irrelevant to address global challenges in this area. The futility of this SDG and limits of the World Health Organization are today painfully clear in the approach of the covid-19 pandemic. Although the crisis was not unexpected, WHO member states have insufficiently invested and left much scope for charities and private investors. The author scrutinizes global public health policies and advocates the creation of a new Jubilee Campaign for indebted countries.
We are awakened to a new reality. The pandemic outbreak by an infectious pathogen comes to no surprise to the Global Health community. The World Health Organization (WHO) has prepared for pandemic scenarios and response plans since over a decade, albeit that they have been written for an influenza virus, not for the coronavirus disease (covid-19) pandemic that we currently face. What is unpresented though is how countries fall back on their own security and economic matters, and that multilateral cooperation is under severe constraints. A large part of the planet’s population is currently under some form of quarantine and travel restrictions. This is unprecedented in human history.
SDGs: conspicuously missing
The G20 came up in March 2020 with a communique that must be read as a massive emergency plan to restore order, economy and public health. It should prevent that the economic disruption will be felt most strongly in the lower-income countries of this world where a ‘third wave’ of the covid-19 outbreak is to be expected. More than 80 Low and middle-income countries have demanded financial help from the IMF to deal with the economic impact of the crisis. The eventual impact on the health outcomes and the health systems will be much deeper and lasting as that of the viral disease itself.
Conspicuously missing in all these emergency actions is a reference to Sustainable Development Goals (SDGs). SDGs are seemingly not a relevant framework for policy guidance during this global crisis. When I visited the UN and NY in September 2019, I came to understand that the SDGs don’t really matter in response to that other looming crisis, the climate emergency. In line with Jan Orbie and Sarah Delputte who wrote that SDGs don’t contribute to trade justice, I argue that SDGs don’t improve health justice or that they are helpful now in the response during a pandemic.
Too little invested in health
Arguably, the SDGs have not been constructed to respond to humanitarian emergencies. Nevertheless they should help countries to mitigate and adapt to such situations. For health security and preparedness, this is covered in ‘Strengthen the capacity of all countries, in particular developing countries to deal with the management of national and global health risks’. This sub-goal entered the SDG framework relatively late as it was a reflection of the lackluster response to the Ebola outbreak in West Africa of 2014-2015. It led Ilona Kickbusch and colleagues to suggest that we would need a specific development goal 18 on global health security as to mitigate future security risks related to public health emergencies.
Despite intensifications of zoonose outbreaks and other vector-borne diseases like Zika, Dengue, and combined with an increasing risk of extensive antimicrobial resistance, has there been way too little international public investments in the capacity to prepare and response to these threats. The Global Health Security index, the first comprehensive assessment and benchmarking of health security across 195 countries, concludes that most countries lack the fundamental healthcare capacity that is vital for responding to an epidemic. The majority of these are low- and middle-income countries that have limited financial and human means to invest in essential public health systems, not even to mention broader social health protection such as Universal Health Coverage (UHC).
The WHO, FIFA and Bill Gates
Unfortunately, but not unsurprisingly, has the global health community very well embraced the multi-stakeholder partnership mantra, articulated in SDG 17. The frame of advancing blended and innovative financing models has become the de facto way of doing development business. Even the mandated UN institution for health, the WHO now feels the need to present an investment case to its member states as to convince them to fund the organization. The SDG logic of health investment being crucial for inclusive economic growth has penetrated deeply in the WHO’s 13th General Program of Work. At the same time have the richer member states, including those in the EU, undermined the WHO by providing mainly tied financing, serving foremost heir domestic interests, rather than securing global public goods such as strengthening the international norms, capacity to detect and responds to public health. Instead, the WHO felt compelled to sign partnerships with FIFA, The World Economic Forum and relies for a considerable amount of its programme budget on philanthropy donations from The Gates, Bloomberg and Rockefeller foundations.
The WHO and partners launched in February a covid-19 solidarity response fund, partly because its member states driven emergency fund has so far only received about just over 50% required for the covid-19 response. The WHO’s Strategic Preparedness and Response Plan called for a total resource requirement of US$675 million to address the covid-19 pandemic. In contrast, the WHO’s solidarity response fund is a charitable partner-driven outlet, managed by the UN foundation and the Swiss Philanthropy foundation who enable tax-deductible online donations facilitated through Facebook fundraiser and Google Donate. The solidarity response fund has reached over US$150 million now. Dr Tedros, WHO’s director general thanked TikTok and GSK, the pharmaceutical company, for their ‘generous contribution of US$10 million’. He welcomed ‘my dear brother Gianni Infantino, President of FIFA’, to talk about our joint campaign to ‘Pass the message to kick out coronavirus’.
It would have been funny if it would not be such an affront to all those communities in both low-income as well as high-income countries that now are facing an epidemic while their social security and health systems had, since the financial crisis a decade ago, to adopt to a global straightjacket of structural adjustment and austerity. In other words; the enormous public health response, a global public good, required by the WHO and broader multilateral community to address the covid-2019 pandemic relies now for a part on the whims of philanthropy and a speculative insurance regime. The WHO member states have allowed, to an extent, the financing of global health security to be left to the celebrities and billionaires of this world.
An empty shell
In addition, US$500 million worth of pandemic emergency financing (PEF) insurance bonds launched in 2017 by the World Bank received much criticism. The criteria to trigger payout is insanely complicated, with the terms relating to high-interest bonds heavily skewed towards private investors, while for the victims any payouts may come too late. The WHO itself calculated that an additional US$274 billion spending on health is needed per year by 2030 to make progress towards the SDG3 health target. UHC remains the overall umbrella SDG goal for the WHO. Twelve multilateral organizations made an SDG3 Global Action Plan (GAP) with the aim to harmonize and synergize the actions by the different signatories. It was launched, with much celebration and high-level attendance, at the last UN General Assembly. However, the SDG3 GAP remains a hollow shell, with limited to no new funding being allocated. Its 4 pillars of Assessing, Aligning, Accelerating and Accounting for the governance of SDG3 remain vague and obfuscate the real political-economy of global health cooperation.
The persistent focus on domestic resource mobilization, matched by blended-finance international investments, had WHO economists conclude that the number of countries requiring ‘sustained development assistance for wage bills (for health personnel) from donor nations is likely to be limited, possibly to as few as 20–30 countries or even fewer’. However, the current economic meltdown indicates that it is a fallacy to expect that 67 Low-Income countries will have the fiscal space available by 2030 to fund basic global health security capacity, letting alone to finance essential health care services and social protection.
Others have written in detail how the SDGs fail to address tax-evasion in an effective manner, how SDGs can’t correct trade injustices, and how they are not preventing or influencing the quickly growing debt-burden of not only low- and middle income countries but even so in higher-income countries in the Eurozone. This will have a huge impact on the determinants of health and access to public services across the board.
The covid-19 pandemic mainly deepens and amplifies an existing undercurrent. It is like a magnifying glass outlining existing health injustices and neglect. And to be clear, this is not only a ‘developing countries issue. It is a universal matter, and ethical debate on the solidarity and functioning of European cooperation as can be seen vividly in relation to the neoliberal ideology (the European economic semester and adjustment policies) that forced Italy to dismantle local health units (from 642 in the 1980s to 101 in 2017) and close down 175 hospitals.
Time for a new Jubilee campaign
In 2015 the health-related SDG already tasted like old wine. By 2020 it is more like acid vinegar. We need to grow new vineyards and let the grapes ripen to become fruit for a rich wine. This would require health systems and its actors to become part of, and to be re-imagined as, a new form of social and ecological contract along the lines of Raworth’s circular Doughnut economy as well as following Degrowth principles.
The vinegar must be thrown out and the record must be set strait. It would start with a debt-moratorium for low-income countries. Let’s reconvene a debt- relief Jubilee campaign as was done in the year 2000. It was at that moment partly fueled by the impact of the HIV-AIDS pandemic on the poorest countries. We now have the covid-19 pandemic in 2020. Could this public health crisis be a tipping point moment for a new Jubilee?
Remco van de Pas is a public health doctor. He is a research fellow at the Institute of Tropical Medicine in Antwerp, an external researcher at the Clingendael institute, and teaches Global Health at Maastricht University. His work focuses on globalization and health, its political-economy and governance, specifically in the domain of health systems, health financing and workforce development.
The Dutch version of this post was published on MO*Magazine.