Reflections from the Global Health Summit, Berlin 2022
Global health is characterized by necessity. Worldwide, the needs of people greatly surpass our ability to meet those needs, and even the most ambitious goals don’t envision a future in which health promotion, protection, and medical assistance will reach every single person in the world when they need it. According to the latest published study regarding the availability of resources for health, the 2019 national health workforces fell short of the minimum established threshold to reach universal health coverage by 6.4 million physicians, 30.6 million nurses and midwives, 3.3 million dentistry personnel, and 2.9 million pharmaceutical personnel. This is only taking into account human resources, not considering the material needs and contextual situations these health professionals would require to do their jobs.
The United Nation’s 17 Sustainable Development Goals (SDG) have set the nomenclature to align worldwide efforts, yet in reality, working towards global health is all about setting priorities- Who will we reach, how will we reach them, and why are we choosing this problem over others?
Another key characteristic of global health is the fact that what is being provided is well-being. Yet well-being does not have a price tag on it: global health is not technically for sale. So, how do we come up with a financial structure for a global good that doesn’t have a price, and whose demand is much greater than the supply?
The financial architecture of global health is fragmented between public and private funds, yet most funds are received from donations. This presents a number of problems, beginning with transparency: while public spending on global health must be carefully accounted for, private donations operate with little to no oversight, creating an accountability “black box”. We can only speculate that these investments tend to reinforce arrangements that favor private interests, and undermine citizen’s power around the world to determine the direction of healthcare provision in their own country.
This translates to the fact that most of the money that is being used to work towards SDGs and global health goals actually comes from the system that is creating the majority of the problems- a global extractivist, impersonal, fossil fueled economy. Understanding this, we should probably drop the term “donation” and start calling foreign aid by what it actually is: a common fiscal project between nations.
This conversation was held in the Berlin World Health Summit 2022 in a Workshop about Global Goods for Health, with the presence of actors from high levels of government, international organizations, and academia. Yet this conversation is not novel; it has probably been discussed in every international political and health summit for the past 20 years. The problem is that there is still no viable solution, and while we wait, it is just getting more and more severe and having new implications.
At the beginning of the Covid-19 pandemic, countries were scrambling to figure out how to react to such a widescale emergency. Most of them turned towards themselves, closing borders and prioritizing the safety and needs of their own citizens: by April 2020, 91% of the world’s population were living in countries with partial or total international mobility restrictions. All the while, global necessity only became more demanding.
Under the Trump administration, the United States was no longer playing their historic role of international coordinator, and their public health officials had their hands full with internal problems. This situation led the path for unprecedented levels of private non-profit funding. Today, there are four privately led organizations that have become the leaders in global health: Bill & Melinda Gates Foundation, Gavi, the Coalition for Epidemic Preparedness and Innovation (CEPI) and the Wellcome Trust. Three of them have been founded by one same man.
This is not to say that there have been negative intentions- someone had to step in and do the job that no one else could or wanted to do. But that job has translated into much more than leading the world’s emergency response to Covid-19. It implies setting the global health agenda and defining the creation of scientific knowledge: Having the power to say what is true and what is not; what is important and what is not.
What does this mean for the legitimacy of science itself?
Max Weber, considered to be one of the founding fathers of sociology, argued that there are three mechanisms through which leaders can obtain their legitimacy. Tradition refers to leaders who have been placed in that position because it is the card they have been dealt, such as monarchs and their heirs to the throne. Charismatic legitimacy pertains to leaders who have come to power due to personal traits or attributes in a certain social context, typically overthrowing traditional or illegitimate leaders through a social revolution. Lastly, rational-legal legitimacy is the one that has been granted through democracy in modern western civilizations: leaders have been chosen by the people in a process that has been established in a social contract.
Clearly, these privately funded organizations aren’t sustained by any of these mechanisms, because their position has been established by wealth and good intentions. Is this enough to create a fourth mechanism in a modern, capitalist global society? To answer this question, we need to ask ourselves what we truly care about.
During a Q&A session with the director of one of the four organizations mentioned above, a man from Irak asked what partnerships or research projects were being carried out in that conflict-driven area of the world. The director did not have a concrete answer, nor did she have an obligation under any means to invest in that territory. If you aren’t legitimate, you cannot be held accountable.
The man’s question pertained to the recognized importance of democratizing, decolonizing and being more inclusive in the way we do science. Historically, the rules on how to “do science” and “discover truths” have been set by the western developed world through the scientific method. Today, there is a growing push to bring more actors to the table: from different parts of the world, with diverse cultural backgrounds and paradigms, of different ages and life-course stages. These efforts don’t seek to question science, on the contrary- they want to make it more legitimate through inclusivity. This was clearly the intention by looking at the composition of almost every panel at the World Health Summit.
This brings us to where we are today- We push for democratic and equal values in all actions we take towards global health, yet the way we finance our actions is inevitably and increasingly contradicting our direction and philosophy. This is by no means a call to detain our efforts- for those of us working in global health philanthropy, we know this is not an option. It is an opportunity for us to reflect on the complex social, economic, and political role we play, and ask ourselves the question:
How do we move forward?
1GBD 2019 Human Resources for Health Collaborators. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2022; 399(10341): 2129-2154.
2Greenberg J, Aluso A. Funding for global health: too much and not enough. Allianve Magazine. 2020. https://www.alliancemagazine.org/feature/funding-for-global-health-too-much-and-not-enough/
3Connor P. More than nine-in-ten people worldwide live in countries with travel restrictions amid COVID-19. Pew Research Center, 2020. https://www.pewresearch.org/?p=361112
4For more on this topic and how this situation came to be about, I highly recommend Politico’s special report published 09/14/2022, How Bill Gates and partners used their clout to control the global Covid response — with little oversight, available at: https://www.politico.com/news/2022/09/14/global-covid-pandemic-response-bill-gates-partners-00053969