Introduction

Amid the COVID-19 pandemic and other health crises, the focus on public health in foreign policy around the world appears to have shifted from ‘low politics’ (humanitarian endeavour) to ‘high politics’ (national and international security concerns).^[1] This shift is accompanied by the emerging need to understand the social, economic, commercial, security, and political determinants of health. These developments have necessitated that ‘health’ be considered as a multisectoral global concern and not just limited to individual countries.

Indeed, the Oslo Ministerial Declaration—signed by Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand in March 2007—had urged the need to broaden the scope of foreign policy to include health. It stated: “Health is deeply interconnected with the environment, trade, economic growth, social development, national security, and human rights and dignity. In a globalised and interdependent world, the state of global health has a profound impact on all nations – developed and developing. Ensuring public health on a global scale is of benefit to all countries.”^[2]

In recent years, no sector—including health—has been spared from ‘VUCA-like’ conditions. VUCA—an acronym for volatility, uncertainty, complexity, and ambiguity—was initially used to describe the uncertainty in the business world, but has since been used to better comprehend unclear situations in diverse fields.^[3] As COVID-19 has shown, global health problems are no longer restricted to the health sector alone.^[4] Consequently, a global shared commitment to the governance, accountability, transparency, endurance, and sustainability of the health system in a VUCA environment is needed to prevent, respond, and prepare for future adverse situations. The Group of Twenty (G20) is one such entity that could enable coordinated collective action against global health challenges.

The G20 is a powerful international platform that discusses and deliberates on pressing issues, and shapes global economic and developmental priorities. The G20 members account for over 80 percent of the world’s GDP, 75 percent of global trade, and 60 percent of the planet’s population.^[5] It has also proved to be an effective crisis management group in its handling of the 2008 global financial crisis through multilateral cooperation and coordination. Over the years, the grouping’s scope has expanded to include the diverse factors that impact the global economy, including health and climate change.

Figure 1: Relative frequency of keywords in G20 Summit documents

Source: Authors’ own

While health was understandably the main focus of the G20 in 2021 amid the pandemic (as depicted in the relative frequency graph of the term’s usage in Figure 1), the grouping showcased its interest in strengthening global health governance in 2017 with the formation of the G20 Health Working Group.^[a] The G20 has also had an indirect impact on the health sector through the grouping’s attempts to address challenges such as climate change, other crises (food, health, water, air, and energy), conflicts, carbon emissions, the mobilisation of global finance for pandemic recovery and climate actions, and technology disruption and access.^[6] This brief seeks to understand the importance of the G20 in addressing global health and associated challenges, and its actions so far. It also proposes a framework for global health governance.

Global Challenges and the G20’s Role

The G20’s focus on health has developed gradually over the years amid greater awareness of the widespread impacts of global health challenges. According to the World Health Organization (WHO), non-communicable diseases (NCDs) are the leading cause of death in high-income countries, while communicable diseases are the main cause in lower-income countries.^[7] This is an important insight given that the G20 includes both high- and low-income countries. A 2019 study showed a high proportional mortality from NCDs among the grouping’s member countries, at 70 percent, mainly in the developed member-countries.^[8] However, collective action is necessary to prevent the global spread of both communicable and NCDs in the future.

National governments are responsible for formulating health mechanisms that are ready, adaptable, affordable, and inclusive to tackle crises in their jurisdictions. But to meet these objectives, governments will have to prioritise and invest in healthcare. While a country’s expenditure on health (as a percentage of GDP) does not entirely indicate its preparedness for a crisis, it does reflect the government’s commitment towards health. In 2019, most developed G20 members spent at least 6 percent of their GDP on health (see Figure 2). In contrast, India, the current G20 chair, spent the lowest, indicating that health was a low domestic priority for the government.

Figure 2: G20 Countries’ Expenditure on Health in 2019 (as a % of GDP)  

Source: World Bank Database^[9]

It is incumbent on the G20 countries to showcase their commitment to building resilient health systems, domestically and globally, as the grouping is also a key contributor in financing development around the world. The group collectively contributes about 90 percent of the Official Development Assistance for global development programmes and agendas in the health sector.^[10] Despite these efforts, almost half the world is unable to access essential healthcare services, with about 100 million people being forced into poverty due to health expenses.^[11] Thus, making healthcare equitable, accessible, and affordable should be a priority for the group.  Notably, for the first time since its establishment, the G20 Troika consists of three developing countries,^[b] giving the grouping an opportunity to reimagine health systems and governance. A starting point could be the wider acceptance of the group’s role in other global crises, such as climate change and its impact on health.

The G20 represents 75 percent of the world’s total greenhouse gas emissions,^[12] but the impacts of this are felt disproportionately more in low-income countries. This necessitates that the group formulate an effective and accountable collective action on climate change. Ineffective action towards climate change could induce climate-sensitive health risks through both direct determinants (such as natural disasters, extreme weather, and diseases breakouts) and social determinants (such as livelihood, migration, and access to and affordability of healthcare).^[13] Although there has been an improvement in carbon pricing among the G20 economies (from 37 percent in 2018 to 49 percent in 2021), it is not enough to curtail the long-term impacts of climate change since over half of CO2 emissions are not yet  priced and due to the uneven distribution of burden among the member states.^[14]  The G20 must ensure that the developed countries—including its members—are held accountable.

At the same time, many G20 countries are popular destinations for migrants worldwide. Despite the pandemic, about 7.5 million temporary and permanent migrants entered the G20 countries in 2020 (although this was a 40-percent decrease compared to 2019 levels).^[15] While there are many reasons for migration, extreme weather events are a major contributor in recent years. The number of ‘environmental refugees’ has risen due to frequent climatic disruptions such as droughts, heatwaves, tsunamis, and earthquakes in many parts of the world.^[16] Since human mobility is a known key social determinant of health at the individual and community level, the G20 countries must take measures to ensure they have comprehensive, preventive, and curative health infrastructure in place to cater to the needs of migrants.^[17]

Mass displacement and migration triggered by changes in the geopolitical environment can also place a strain on global health systems. As of December 2022, following the Taliban’s takeover of Afghanistan in 2021, 3.4 million people have been displaced internally, and 2.1 million have sought refuge or asylum in the neighbouring countries.^[18] Additionally, over 12 million people have fled their homes since the start of Russia’s war in Ukraine in February 2022, with 7.8 million entering European Union countries as refugees and over 4.7 million applying for temporary residence elsewhere.^[19]

The G20 must place health at the top of its priorities due to its potential in the pharmaceutical sector, health data governance, and health technologies. Forty-six of the top 50 pharmaceutical companies worldwide are situated in the G20 countries.^[20] With over 78 percent of the global market for pharmaceuticals dominated by the G20, it has the potential to reduce the production of counterfeit and substandard medicines, and propel the industry to produce affordable medication to address both communicable and NCDs.^[21] As was seen during COVID-19, countries with strong pharmaceutical industries can play a major role in the production and distribution of medicines and vaccines. The pandemic also highlighted the need to strengthen global value and supply chains for medicine and vaccine production.^[22] The G20 countries have been central to the discussion on vaccine equity, given that they are said to have received 15 times more COVID-19 vaccine doses than Sub-Saharan Africa.^[23] The G20 has a responsibility to help build resilient value chains that can enable the cost-effective production of vaccines and medical devices, and make them accessible and affordable to people across the globe.

The G20’s actions so far

Over the years, the G20 has taken several vital steps towards addressing global health challenges, with the group adopting 75 health commitments between 2011 and 2019.^[24]  Even between 2008 and 2012, when the G20’s priority was global financial stability, the grouping still focused on ensuring that peoples’ welfare was not compromised by austerity measures. During this phase, the group’s health-related agendas involved strengthening social safety nets such as public healthcare and pension plans.^[25] Over the next three year (2013-2015), health was included indirectly through discussions on food security, nutrition, and environmental sustainability. ^[26]

Between 2016 and 2019, there was an increased commitment towards health, with anti-microbial resistance (AMR) posing a threat to public health and global economic stability. The priority was on investing in research and development to tackle AMRs by working with other international organisations such as the WHO, Food and Agricultural Organization, World Organization for Animal Health, and the Organisation for Economic Co-operation and Development. Amid the Ebola and Zika outbreaks, the G20 also realised its role in advancing preparedness and responsiveness to such global health challenges.^[27] To strengthen the health system, discussions were focused on formulating sufficient and sustainable funding measures, including a rapid financing mechanism. The launch of the G20 Health Working Group in 2017 solidified the group’s role in global health governance.

The COVID-19 pandemic has tested the effectiveness of the G20’s previous measures to strengthen the global health system. Still, the group was quick to respond to the crisis with a ‘G20 Action Plan’ that prioritised cooperation among the different stakeholders in the health, economic, and financial sectors.^[28] The G20 members promoted multilateral cooperation and actions focused on limiting the health crisis and its subsequent economic fallout. The group also prioritised digital health, establishing the G20 Digital Health Taskforce during the Saudi Arabia presidency in 2020 to leverage digital health interventions and promote supportive policies.^[29] In 2021, the G20 also established a Joint Finance and Health Taskforce to strengthen pandemic prevention, preparedness and response.^[30] India has already stated that tackling the resurgence of COVID-19 or similar pandemics will be a policy priority during its G20 presidency.^[31]

Although the G20 has made promising efforts to address global health challenges, geopolitical conflicts involving the member countries, either directly or indirectly, could scuttle any progress on tackling these issues.

Since its inception, the G20 has positioned itself as a ‘crisis solver’.^[32] However, it has faced increased criticism in recent times over its inadequacy in addressing trade, economic, and sustainable development challenges during the pandemic.^[33] The group has also been criticised for its compliance commitment gap (the difference between the number of stated commitments and complied ones). From 2008 to 2020, it has managed to achieve an average compliance score of 86 percent, with some variance over the years.^[34]

Additionally, while the estimated damage due to COVID-19 is around US$12.5 trillion, the G20—which includes some of the most developed countries in the world—has only pledged US$1.4 billion to the World Bank’s ‘Pandemic Fund’.^[35] This wide gap in financing the recovery from the pandemic has led some critics to note that group’s “representative legitimacy has not translated into expedient efficacy”.^[36] To address such a critical challenge, the G20 must increase its efficacy through effective dialogues and meetings and have a compliance mechanism to measure progress.

Health Governance Under India’s Presidency: A Proposed Framework

During the height of the COVID-19 pandemic, G20 discussions and deliberations were mainly focused on the management of the disease, vaccine rollouts, and strengthening the public health system to withstand future pandemics. Developing and strengthening global health architecture was a key priority of the Indonesian presidency in 2022, with a focus on making health equitable, inclusive, and responsive.

The Bali Leaders’ Declaration document makes a clear commitment for the group to be more involved in global health governance and improving pandemic preparedness and response, with an emphasis on the finance and health ministers working together to support the World Bank’s ‘Pandemic Fund’.^[37] Although the G20’s prioritisation of health has reduced as compared to previous summits (see Figure 1), the Leaders’ Declaration addresses global health concerns indirectly. Geopolitical conflicts, rising inflation, and growing unemployment has given rise to the need to strengthen food security. Access to affordable nutrition has a direct impact on people’s health and wellbeing. India must further these initiatives in 2023, and this will feed into the theme of its presidency—Vasudaiva Kutumbakam (One Earth, One Family, One Future).^[38]

Improving the G20’s cohesion should be a priority task during India’s presidency if the group is to make any progress on global economic and development commitments. India’s efforts to strengthen global health governance can be guided by a framework that emphasises collective cooperation and implementation (see Figure 3). India can bring the group closer together by leveraging its ‘multi-alignment’ approach to foreign policy. Such cooperation at the G20 could act as a base for collective implementation at multiple levels. The understanding and convergence of collective action among the G20 countries can further enable reforms in international organisations and regulations that facilitate global health resilience. While cooperation and commitments are made at a global level, national and subnational commitments will be crucial for the effective implementation of the vision and policies proposed by the preceding levels.

Although the framework stresses a global-to-local commitment approach, the sectors and actors involved in this process are interdependent across levels. As the social and economic position and the context for health vary at the global, national, and subnational levels, the G20 interventions need to be context-specific and equitable.^[39] As such, the framework also encourages global initiatives and reforms to learn from individual behaviours and local cultural practices in health and related challenges, as proposed by the Indian government’s LiFE (Lifestyle for Environment) strategy.^[40]

Figure 3: Proposed Framework for Global Health Governance

Source: Authors’ own

The framework could be applied when considering and implementing international health regulations reforms. The G20 countries can shape reforms through discussions and cooperation amongst themselves and with the WHO. Next, the group could push for equitable and sustainable reforms during the deliberations and discussions at the World Health Assembly. The implementation of such reforms can only be made with the assurance of national and subnational entities. India has already provided a nine-point reform plan to the WHO with an emphasis on international health regulations.^[41] This should guide its discussions on health governance at the G20 level and at other multilateral platforms. Within India, while a national commitment has been articulated, the states will also need to comply with these reforms through rules and regulations. As such, greater cohesion will enable the independent levels to implement reforms and action for positive impact by involving state and non-state actors in the governance of global health.

Conclusion

In a continued VUCA-like global environment, the G20 can play a key role in addressing health—and other—challenges. Strengthening cooperation on and consistency in the G20’s priorities through enhanced cohesion and collective action will help prepare for future global health crises. Further investigation into the effectiveness of G20 commitments and compliance is necessary for the group to be more accountable to itself and the world. A strategic vision to increase its competencies could encourage cooperation between member countries and enable effective diplomatic dialogue during geopolitical tensions and otherwise. During its presidency, India must encourage multilateral cooperation and collaboration for inclusive, equitable, and sustainable growth at the local, national, and global level.

Endnotes

^[a] The G20 Health Working Group was established to develop a shared commitment to address global health challenges such as malnutrition, health crises management, antimicrobial resistance, universal health coverage, and building resilient health systems.

^[b] The Troika consists of the past (Indonesia), current (India), and incoming (Brazil) chairs.

^[1] David P. Fidler, "Health as foreign policy: harnessing globalization for health," Health Promotion International, (2006): 51-58.

^[2] Ministers Of Foreign Affairs Of Brazil France Indonesia Norway Senegal South Africa And Thailand, “Oslo Ministerial Declaration—Global Health: A Pressing Foreign Policy Issue of Our Time,” The Lancet 369, no. 9570 (2007): 1373–78.

^[3] Christoph Schulze et al, “Public Health Leadership in a VUCA World Environment: Lessons Learned during the Regional Emergency Rollout of SARS-COV-2 Vaccinations in Heidelberg, Germany, during the COVID-19 Pandemic,” Vaccines 9, no. 8 (2021).

^[4] European Commission, The Sectoral Impacts of the COVID-19 Crisis, Brussels, European Commission, 2021.

^[5] G20 India, “About the G20”, G20 India.

^[6] Luiz de Mello, Sveinbjorn Blondal, and Nigel Pain, The Covid-19 crisis and the global economy: Challenges and policy requirements, Saudi Arabia, Think 20 Saudi Arabia, 2020.

^[7] “The Top 10 Causes of Death,” World Health Organization, December 9, 2020.

^[8] Hidechika Akashi et al, “The Role of the G20 Economies in Global Health,” Global Health & Medicine 1, no. 1 (2019): 11–15.

^[9] The World Bank, “Current health expenditure (% of GDP)”, The World Bank.

^[10] Bronwyn McBride, Sarah Hawkes, and Kent Buse, "Soft power and global health: the sustainable development goals (SDGs) era health agendas of the G7, G20 and BRICS," BMC Public Health 19, no. 1 (2019): 1-14.

^[11] Mamiko Yoshizu et al, “World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses”, World Health Organization, December 13, 2017.

^[12] Silvia Amaro, “G-20 Nations Have Gathered to Talk Carbon Emissions. The Negotiations Won't Be Easy,” CNBC, August 31, 2022.

^[13] “Climate change and health,” World Health Organization, October 30, 2021.

^[14] OECD, Carbon Pricing in Times of COVID-19: What Has Changed in G20 Economies?, Paris, OECD, 2021.

^[15] OECD, 2021 Annual International Migration and Forced Displacement Trends and Policies Report to the G20, OECD, 2021.

^[16] UNESCO, “Climate induced Migration,” UNESCO, 2017.

^[17] International Organization for Migration, “Migration Health,” International Organization for Migration, 2021.

^[18] United Nations High Commissioner for Refugees, External Update: Afghanistan Situation #22, UNHCR Regional Bureau for Asia and Pacific, 2022.

^[19] United Nations High Commissioner for Refugees, “Operational Data Portal,” Ukraine Refugee Situation.

^[20] Michael Christel, “2021 Pharm Exec Top 50 Companies,” Pharmaceutical Executive, no. 41 (2021).

^[21] Hidechika et al, “The Role of the G20 Economies in Global Health.”

^[22] Terri Chapman, Jhanvi Tripathi, and Rakesh Kumar Sinha, Building Resilient Global Value Chain Linkages in India: Findings from an Enterprise Survey, Observer Research Foundation, 2022.

^[23] Sema Hosta, “G20 Members Have Received 15 Times More COVID-19 Vaccine Doses per Capita than Sub-Saharan African Countries,” UNICEF, October 27, 2021.

^[24]  Ilona Kickbusch et al, “Global Health Diplomacy in a Changing Multilateral System,” Essay. In A Guide to Global Health Diplomacy, edited by, 19–36. Geneva, Switzerland: Global Health Centre, 2021.

^[25] Zaria Shaw et al, G20 Leaders’ Conclusion on Health, 2008-2019, G20 Research Group, University of Toronto, 2019.

^[26] “G20 Leaders’ Conclusion on Health, 2008-2019”

^[27] Michael G Head et al, “The allocation of US$105 billion in global funding from G20 countries for infectious disease research between 2000 and 2017: a content analysis of investments,” The Lancet Global Health 8, no. 10 (2020): 1295-1304.

^[28] G20 Saudi Arabia, Communique – G20 Finance Ministers and Central Bank Governors Meeting, G20 Saudi Arabia Presidency, 2020.

^[29] “G20 First-time Released Report on Digital Health Interventions for Pandemic Management,” World Health Organization, December 7, 2020.

^[30] “Delivering on the G20 Leaders commitment to build an equitable and effective Financial Intermediary Fund (FIF) for Pandemic Preparedness and Response (PPR),” World Health Organization, April 19, 2022.

^[31] Prerana Katiyar, “Digital Health will be a Key Priority in India’s G20 Presidency,” The Economic Times, November 26, 2022.

^[32] Bernice Lee, comment on “G20 Must Live up to Its Crisis-Solving Legacy,” Chatham House – International Affairs Think Tank, comment posted December 21, 2021.

^[33] Shruti Jain, “Fault Lines at the G20,” Observer Research Foundation, November 11, 2021.

^[34] Kaylin Dawe, Jae Yoon Mary Noh, and Alexander Ignatov, 2020 G20 Riyadh Summit Final Compliance Report, University of Toronto, G20 Research Group, 2021.

^[35] David Fidler, comment on “At Bali, the G20 Confronts Multidimensional Crises with Empty Diplomatic Rhetoric,” Think Global Health, comment posted November 22, 2022.

^[36] Tristen Naylor, comment on “The Return of Politics,” The Global Governance Project, comment posted October 28, 2022.

^[37] G20 Indonesia, G20 Bali Leaders’ Declaration, November 2022, Bali, G20 Indonesia, 2022.

^[38] Prime Minister’s Office, Government of India.

^[39] Finn Diderichsen, Resource allocation for health equity: issues and methods, World Bank, 2004.

^[40] NITI Ayog, “LiFE: Life Style for Environment,” NITI Ayog, 2022.

^[41] Government of India, Approach on WHO Reforms, Government of India, 2020.

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