What opportunities does Spain have to increase its international influence amid the transformations in global health governance following the COVID-19 pandemic?
Among the many consequences of the COVID-19 pandemic, the most predictable are related to the importance placed on global health in the international agenda and the transformation of the world’s health system. This analysis sets out to determine the impact of this crisis on the international actors, spaces and issues in the healthcare domain. Understanding the debates and dynamics of this process is an opportunity for Spain. Unravelling where and how the most wide-reaching decisions for global health are being taken is fundamental to wielding the type of influence capable of redefining Spain’s position within the international community.
The COVID-19 pandemic has put the international community’s ability to respond to the worldwide spread of infectious disease to a severe test. This has promoted global health to a prominent position in the multilateral policy agenda over the past two years, given the need to fashion a response to a security threat of the first order. The importance of health has materialised around the dimensions of security and development, with clear geopolitical consequences.
The first dimension is health security: how to respond to a threat posed by the spread of a disease beyond the borders of any individual state and that requires cooperation between them in order to contain it. This question has had a place in international policy since the end of the 19th century; coordination aimed at containing these threats has formed part of the mandate of the World Health Organisation (WHO) since its creation in 1948 and is the goal of the 2005 International Health Regulations (IHR), a legally-binding instrument of international law that determines the international health security system. The tension that this framework was subjected to with SARS-Cov2 has revealed the extent to which the shortcomings in the implementation and enforcement of the regulations were crucial in the immediate response to the outbreak, which later became a pandemic. As well as the clear need to bring these regulations up to date on the basis of the lessons drawn from the COVID-19 response, there is also a debate about the WHO’s lack of authority when addressing states’ non-compliance. This has given rise to an initiative to develop a new international instrument revolving around the preparation and response capabilities to pandemics. This is something that is currently being worked on at the behest of the World Health Assembly, the WHO’s governing body.
The second dimension of health that needs to be underscored concerns its basic role in human and communal development. This too is a longstanding feature of the international agenda, of which it has formed part for decades through official development aid and cooperation. The adoption of the Sustainable Development Goals (SDGs) in 2015 made Universal Health Coverage (UHC) the key to achieving the various targets of the 2030 Agenda in the healthcare field. In 2019, in the context of the UN General Assembly, a high-level policy conference was held whose final communiqué reaffirmed the world leaders’ commitment. In order to make progress towards UHC, the fundamental goals of aid policies in the health sector are the strengthening of systems and the progressiveness of their care provision. The impact of COVID-19, however, threatens to substantially undermine the trends that have made the achievements of the last two decades possible. And it has also laid bare the fact that the stark inequality in the starting positions of national health systems throughout the world –the first line of defence against this threat– is the greatest vulnerability in combatting it.
Both of these dimensions are linked to a third, geopolitics, which is the consequence of the two previous ones: there is a geopolitical dimension to global health because there is a new debate surrounding the threats to global health security; but also because a challenge persists in terms of equity concerning health and human development, which is still far from being resolved. Meanwhile, the latter dimension has turned the two previous ones into elements of growing importance for states’ positions and influence in the international community. This is exemplified by vaccines, and the negotiating positions from which the countries of the global South have approached the pandemic treaty, demanding a world health system that attends to their own priorities and needs to be more equitable.
It is worth using these three dimensions to try to understand the impact of the pandemic on the spaces and actors in global health, as well as the transformation that their roles, positions and relationships are being subjected to. The importance of understanding the nature of this transformation and the possibilities of having a bearing on it lie in the fact that, as with the climate crisis, only multilateral action can generate an effective response to the major threats of our times.
What are the international spaces in which global health policy is being decided?
This section starts with an analysis of the role that the WHO is playing in the response to the pandemic, with a focus on the limitations that have been found in terms of exercising political leadership over the crisis. In contrast to this, there is an analysis of the specific initiatives and actions sponsored in other domains such as the G7 and particularly the G20, ending with a review of the role of regional organisations.
The fact that the greatest crisis experienced since the Second World War has been a health crisis has shone a spotlight on the conduct of the WHO, pushed to the brink by the pandemic. It is worth distinguishing between two levels in its response: at a technical level it has played a crucial role, particularly in declaring the global health emergency (although not in its prevention) and in setting out the guidelines for halting the spread of SARS-Cov2. It also played a fundamental role as a source of authorised information based on the best scientific evidence available at the time. This enabled answers to be given to the countless rumours and fake news stories that spread throughout the world faster than the virus itself. At a political level, however, it fell well short of being the central governing body of world health capable of leading the global response to a critical situation.
The fundamental reasons for this limitation are threefold and entirely interrelated. The first, which almost goes without saying in the context of international politics, is the lack of authority to compel states and sanction them. Like a large number of the institutions set up after World War II, the WHO made consensus the fundamental dynamic in its decision-making processes. This system has been showing signs of obsolescence for years, but the pandemic has revealed its inadequacy for creating an effective response to a global crisis such as the one unleashed by COVID-19. Herein lies the second limitation: the WHO’s lack of autonomy. Despite the legitimacy it acquires from its specialisation in the health field, this counted for nothing when it turned into a top-priority political issue. Its dependence on the political positions of the states that comprise and fund it has become obvious, especially in the extent to which the major challenges faced by the WHO have been posed by the main international powers. In the early and decisive moments of the COVID-19 outbreak, China blocked the organisation from immediately sending experts to probe its origins. In the US, the Trump Administration accused it of conniving with the Chinese authorities and went as far as to announce US withdrawal, something that never happened owing to the presidential handover in the world’s largest economy.
The third barrier preventing the WHO from acting as a centre of governance for world health is structural in nature and emanates from something referred to in the preceding paragraph. This involves its system of funding. The 194 states that comprise it and take the decisions in its governing body, the World Health Assembly, contribute to the organisation’s regular budget through compulsory contributions. This is what funds its structure and the basic capabilities stemming from its mandate. The problem resides in the fact that this accounts for only 20% of the WHO’s latest two-yearly budget. Eighty percent of this comes from voluntary contributions from public and private actors which, in a results-focused way, are geared towards specific programmes and interventions set by the priorities and mandates of the funding entities. As an upshot of all this, according to the severest critics, the organisation’s working agenda has been distorted owing to such private goals and priorities.
A fundamental aspect of this question is related to the importance that fiduciary funds and multilateral initiatives have acquired in the past two decades in the area of global health. Under the umbrella of the Millennium Declaration, these new actors on the global health stage have joined the efforts of public and private actors, mobilising considerable resources that have turned them into the great funders of world health and of the WHO itself. This has furnished them with significant influence in the global health system that has not been devoid of controversy. The main criticism has been, in the past, their focus on vertical interventions in highly specific areas such as the fight against the three great pandemics (the Global Fund to Fight AIDS, Tuberculosis and Malaria), and the vaccination of those aged under five (GAVI, the Global Alliance for Vaccines and Immunisation). But set against all these criticisms, their focus on the impact and the dynamism of the decision-making and management mechanisms has turned them into the great catalysts of the progress made in recent years in the health field. The fact is that, by virtue of this, the governing bodies of these initiatives have taken critical decisions of far greater impact on global health than many other players. This makes it essential to acknowledge the role played by these new actors in the governance of global health in a way that better accords with reality.
Various international initiatives and panels of experts have been convened in recent months with the explicit purpose of analysing the response to the pandemic and drawing conclusions in anticipation of new crises of this nature. Their findings agree on the need to strengthen the powers of the WHO as a cornerstone of the global health system. The work is focusing on two areas: the funding of global health (which includes specific proposals for reforming the WHO’s funding system) and improving preparation and response capacities to pandemics (for which work is being done on setting up a specific international instrument). What is not being proposed is a wide-ranging debate about the governance of global health that recognises the aforementioned limitations as hindrances holding back the WHO’s leadership of the pandemic response.
This accounts for the importance of analysing which spaces have been the main drivers of international political action in the response to the pandemic. Specifically, it has been the G7 and particularly the G20 that have performed this role. For years these forums have brought together the highest-ranking governmental representation of the countries that comprise them to agree and coordinate multilateral action. Even before the current crisis, global health was gaining importance on their respective working agendas, as confirmed by the study conducted by the University of Toronto’s research groups looking into both the G7 and the G20. This growing importance may be attributed to three fundamental spurs: (1) the impact that the Ebola outbreak in West Africa (2014) had on the international agenda; (2) the growing awareness of anti-microbial resistance (the other great threat to health in our times, which is becoming ever more manifest); and (3) the leadership role played by Germany in this area in the rotating presidencies of these forums in recent years.
In the case of the G20, under the presidency of Saudi Arabia, in mid-April 2020 the meeting of Finance Ministers passed a plan of action in response to COVID-19, the first section of which focused on the health response. As well as explicitly acknowledging the leadership of the WHO and the regulatory framework of the IHR, this placed special emphasis on the specific funding needs of global health initiatives and access to vaccines, treatments and diagnoses. It also included a specific call for financial contributions to the issue, something that materialised a few days later with the approval of an action plan underwritten by the G20 for the launch of the ACT Accelerator. It was also agreed to set up the High Level Independent Panel on financing the global commons for pandemic preparedness and response, with the mandate of forming concrete proposals on the funding of global health. In May 2021, under the Italian presidency of the G20, the Global Health Summit was held, co-organised with the EU. Its final communiqué lists 16 principles that together make up a road map for global health beyond the pandemic. Follow-up of the commitments has been included in the working agendas of the Health and Finance Ministers and the leaders’ summits.
As far as the G7 is concerned, the start of the pandemic coincided with the US taking over the presidency of the forum. The stance taken by the Trump Administration, foreswearing global leadership in the midst of nationalist retrenchment, leant greater prominence to the role of the G20 at this time. The UK’s taking over of the reins in 2021 and the handover of the US presidency reactivated this forum. And it did so by devoting a major part of its 2021 working agenda to global health. Here it is worth highlighting the evaluation that was conducted for the Cornwall Summit, held in June, of the commitments acquired by the G7 members regarding Universal Health Coverage. It was also at this meeting that a commitment was made to donate 1 billion COVID-19 vaccine doses as a response to low-income countries’ lack of access to vaccines.
Both the G20 and the G7 have proved fundamental advocates of the ACT-A initiative, created as an ad hoc response to COVID-19 with a mandate tied in to the pandemic. This initiative brings together the interventions arrayed against SARS-Cov2 of the large fiduciary funds and specialist multilateral initiatives mentioned above. Its launch, under the leadership of the WHO’s technical expertise, has sought to address the significant problem of unequal access to COVID-19 vaccines, treatments and diagnoses. To this end they have managed to coordinate the mobilisation of the largest ever allocation of resources devoted to low-income countries, in which these organisations already operate. Despite the fact that neither of the arms of the initiative has achieved the goals set out at the time of its creation, the role that they have played in response to the pandemic has revealed the de facto influence that these initiatives have in the governance of global health.
|COVAX: the vaccine arm of the ACT-Accelerator initiative It is worth pausing to consider the vaccine arm of the initiative, COVAX. In terms of attainment of its goals, unlike the others, it obtained the necessary funding at the start of 2021 for the acquisition of enough vaccine doses to enable it to meet its targets. It did not do so owing to the succession of obstacles it faced over the course of 2021. The greatest of these was the competition for the acquisition of vaccine doses in the market it faced from its own donors, the wealthiest countries which had cornered the production of the first approved vaccines. Another fundamental obstacle was the nationalist prism through which many countries addressed the management of the pandemic. In the specific case of India this meant a ban, for more than seven months, on exports from the world’s largest producer of COVID-19 vaccines, the Serum Institute, with which COVAX had agreed its main contract for supply. In the end, trying to react to the shortage of supply experienced throughout a considerable part of the year, COVAX played a role for which it was not designed. It set itself up as the main distribution mechanism for donated vaccine doses. The logistical challenges of this distribution and the uncertainty surrounding the quantity and delivery times of these doses underlie the complaints and criticisms of many recipient countries. All these difficulties faced by the initiative go some way to explain the stark inequalities in the vaccine response to COVID-19 in Africa, situated at below 10%, while the populations of Europe and North America are receiving their third doses. Despite everything, at the start of January 2022, COVAX had distributed more than 989 million vaccine doses in 144 countries and was the intervention with the greatest impact in efforts to counteract inequality in vaccine access. In order to carry out its interventions, COVAX uses GAVI’s legal staff and decision-making mechanisms. These are spaces where decisions are made with an impact on global health, such as the list of countries eligible to receive the vaccines subsidised by the initiative.|
The final point that needs to be made is the role that regional organisations have played in the response to the pandemic. The case of the EU has been paradigmatic by collectively addressing not only the acquisition of vaccines for all its member states but also supplying the funding needed to revive their economies in the years to come. While the European case is not comparable with any other process of regional integration, the experience of tackling a global crisis in a collective manner reaffirms the importance of taking such processes further. In the case of Spain, the influence that may be deployed in these spaces is particularly important. This certainly applies to the EU, but also to strategic geographical areas such as Latin America (through the Ibero-American Summits) and the Mediterranean.
In short, at a time when global health represents an important part of the international agenda, the decision-making spaces and process with the greatest impact on health are being redefined outside the prevailing United Nations system. A result of this is that a new international positioning is occurring involving the actors with the most power and influence in the most sensitive decisions affecting greater numbers of people.
Germany has pioneered a trail that Spain could follow
Germany provides a clear example of how placing strategic priority on global health can make it possible to achieve an influence that has turned into leadership in less than a decade. It is a journey that repays study and started with the drawing up in 2013 of the German government’s first strategy paper, Shaping Global Health, which already hinted at some distinctive characteristics. Notable among these was a desire to transcend the strict confines of development aid while maintaining the reinforcement of health systems as a priority. It proposes that Germany’s contributions to global health be focused on areas where it can provide added value for better health protection against transnational threats. How this can be achieved comprises three key elements: (1) intersectoral cooperation; (2) promoting the role of research and the healthcare industry; and (3) underpinning the architecture of global health. In this last respect, Germany has deployed an entire strategy of international influence in spaces that range from the executive bodies of the WHO to the prioritisation of health through specific measures during the rotating presidencies of the Council of the EU, the G7 and the G20.
In October 2020 the German government updated this approach, tailoring it to the framework of the 2030 Agenda and the context of the pandemic. The outcome was a strategy titled ‘Responsibility, innovation, partnership: shaping global health together’. This set out three groups of strategic goals: (1) prioritising areas of added value from a cross-sectoral perspective and in line with the One Health approach, seeking systemic impact; (2) strengthening Germany’s political position in a global health architecture that has the WHO as its cornerstone and aspires to broaden regional partnerships; and (3) incorporating different areas of the federal government, as well as dialogue and exchanges with non-state actors. It aspires to the internationalisation of initiatives, a greater presence of professionals and expert personnel in global health institutions and the mobilisation of resources to shape the responses of the international system to the challenges of global health.
This strategic planning and orientation towards impacts differentiates the German case from other countries whose leadership in global health has emanated almost exclusively from Official Development Assistance. The US, the UK and to a lesser extent France remain the principal donors in the sector, followed by Germany. For a mid-size power such as Spain, which would struggle to match these countries’ volume of ODA devoted to health, Germany provides an example for aspiring to leadership based on influence and the mobilisation of contributions to global health, beyond the traditional ODA sectors and actors.
In fact, Spain’s response to the pandemic has made some progress in this regard, and was already making headway with the major announcements made at the 2019 United Nations General Assembly. The commitment to universal access to vaccines, as well as the funding contributions to COVAX, was consolidated in January 2021 with the approval of the ‘Universal Access Plan. Sharing vaccines against Covid-19 “Solidarity Vaccination”’ months before the international community started announcing commitments in this regard, which has made Spain one of the largest donors of vaccine shots worldwide, and second in Latin America after the US. In May, the ‘Vaccines for all’ initiative set out a series of measures and commitments to sharing knowledge as a way of addressing the obstacles to the production and distribution of vaccines worldwide. Notable among these was a favourable stance towards an agreement on temporary exemption from patents submitted to the World Trade Organisation to respond to COVID-19. This places Spain closer to the position of the partner countries involved in Spanish aid to Latin America and Africa than that of the other EU member states. In November, Spain also became the first country to strike an agreement with the COVID-19 Technology Access Pool (C-TAP) platform to license a serological antibody test developed by the Spanish National Research Council.
The vaccine example could be Spain’s first step in developing a strategic vision of global health with which to redefine its position and influence in the world. Three aspects need to be particularly borne in mind for this to be achieved: (1) the inclusion of scientific research and health management as areas in which Spain contributes added value; (2) the prioritisation of international forums and initiatives with the greatest impact; and (3) the need for sufficient resources and the political will to implement it.
The pandemic has turned global health into a political issue of the first order, but also served as a reminder of the limitations affecting its governance. The health crisis has been exacerbated by systemic inequality, which has received significant coverage, and as a consequence of this health has established itself as a new area of global geopolitics. There is a need to review and update regulatory and institutional frameworks, and in doing so it is essential that room is clearly and appropriately made in them for a plurality of actors and sectors that have for years been discharging a key function in the context of health.
The agenda of issues, actors and political forums briefly addressed in this analysis determines the framework within which the transformation of the global health system is being set out and the debates and challenges that will need to be settled. Together with the climate crisis, and intimately connected to it, the issue of global health emerges in a context that needs to catalyse the most effective multilateral response possible. The various actors are jockeying and mobilising their influence to shape this new system, in which Spain has the opportunity to become an important player. The example of Germany provides a local benchmark as a starting point, and this can be joined by the added value of one of the most robust health systems in the world, despite the impact of austerity and the pandemic.
Wielding such influence by Spain should be based on a holistic understanding of these new forums and their mechanisms of governance and give rise to a shared vision of the areas in which Spain provides the greatest added value. This should be geared towards impacts and innovation, mobilising through partnerships all the capabilities of its public and private sectors: a strategic approach to global health with its own seal of identity that would mark a new position for Spain on the international stage.
 The fundamental reports for this analysis are: ‘Covid-19: make it the last pandemic’, Independent Panel for Pandemic Preparedness and Response, May 2021 (panel created by order of the World Health Assembly in 2021); ‘Losing time: end this pandemic and secure the future’, Former co-chairs of the Independent Panel, November 2021 (a report following six months of monitoring); and ‘A global deal for our pandemic age’, High Level Independent Panel on Financing the Global Common Goods for Pandemic Preparedness and Response, July 2021 (panel set up by the G20 Finance Ministers and central bank Governors). Recourse has also been made to the final and draft reports of both of the WHO’s working groups: the 24 November 2021 draft Report of the Working Group on Sustainable Finance and the report submitted to the extraordinary session of the World Health Assembly in November 2021 by the member states’ working group on Strengthening WHO Preparedness and Response to Health Emergencies.
Image: Covid-19 poster. Photo: Ystallonne Alves.